Methadone dose increase and abstinence reinforcement for treatment of continued heroin use during methadone maintenance

Empirically contrasting urine drug screening-based opioid use disorder treatment outcome definitions

BACKGROUND AND AIMS

A lack of consensus on the optimal outcome measures to assess opioid use disorder (OUD) treatment efficacy and their precise definition and computation has hampered the pooling of research data for evidence synthesis and meta-analyses. This study aimed to empirically contrast multiple clinical trial definitions of treatment success by applying them to the same dataset.

METHODS

Data analysis used a suite of functions, developed as a software package for the R language, to operationalize 61 treatment outcome definitions based on urine drug screening (UDS) results. Outcome definitions were derived from clinical trials that are among the most influential in the OUD treatment field. Outcome functions were applied to a harmonized dataset from three large-scale National Drug Abuse Treatment Clinical Trials Network (CTN) studies, which tested various medication for OUD (MOUD) options (n = 2492). Hierarchical clustering was employed to empirically contrast outcome definitions.

RESULTS

The optimal number of clusters identified was three. Cluster 1, comprising eight definitions focused on detecting opioid-positive UDS, did not include missing UDS in outcome calculations, potentially resulting in inflated rates of treatment success. Cluster 2, with the highest variability, included 10 definitions characterized by strict criteria for treatment success, relying heavily on UDS results from either a brief period or a single study visit. The 43 definitions in Cluster 3 represented a diverse range of outcomes, conceptualized as measuring abstinence, use reduction and relapse. These definitions potentially offer more balanced measures of treatment success or failure, as they avoid the extreme methodologies characteristic of Clusters 1 and 2.

CONCLUSIONS

Clinical trials using urine drug screening (UDS) for objective substance use assessment in outcome definitions should consider (1) incorporating missing UDS data in outcome computation and (2) avoiding over-reliance on UDS data confined to a short time frame or the occurrence of a single positive urine test following a period of abstinence.

Retention of people who inject drugs enrolled in a 'medications for opioid use disorder' (MOUD) programme in Uganda

BACKGROUND

Injection Drug use is associated with increased HIV risk behaviour that may result in the transmission of HIV and poor access to HIV prevention and treatment. In 2020, Uganda introduced the 'medication for opioid use disorder (MOUD) treatment' for People who inject drugs (PWID). We analysed the 12-month retention and associated factors among PWID enrolled on MOUD treatment in Kampala, Uganda.

METHODS

We conducted a retrospective analysis of 343 PWID with OUD who completed 14 days of methadone induction from September 2020 to July 2022. Retention was defined as the number of individuals still in the programme divided by the total number enrolled, computed at 3-, 6-, 9-, and 12 months using lifetable and Kaplan-Meier survival analyses. Cox proportional regression analyses were conducted to assess factors associated with retention in the programme in the first 12 months.

RESULTS

Overall, 243 (71%) of 343 participants stabilized at a methadone dose of 60 mg or more. The majority of participants were males (n = 284, 82.8%), and the median (interquartile range, IQR) age was 31 (26-38) years. Most participants (n = 276, 80.5%) lived 5 km or more away from the MOUD clinic. Thirty (8.8%) were HIV-positive, 52 (15.7%) had a major mental illness and 96 (27.9%) had a history of taking alcohol three months before enrollment. The cumulative retention significantly declined from 83.4% (95%CI = 79.0-87.0) at 3months to 71.9% (95%CI = 67.2-76.6) at 6months, 64% 95%CI = 58.7-68.9) at 9months, and 55.2%; 95% CI (49.8-60.3% at 12months. The 12-month retention was significantly higher for participants on methadone doses of 60 mg or more (adj.HR = 2.1, 95%CI = 1.41-3.22), while participants resident within 5 km of the MOUD clinic were 4.9 times more likely to be retained at 12 months, compared to those residing 5 km or more, (adj. HR = 4.81, 95%CI = 1.54-15). Other factors, including predisposing, need, and enabling factors, were not associated with retention.

CONCLUSION

Our study demonstrates acceptable 12-month retention rates for people who inject drugs, comparable to previous studies done in both developing and developed countries. Sustaining and improving retention may require enhanced scaling up of MOUD dose to an optimal level in the first 14 days and reducing the distance between participant locale and MOUD clinics.

Optimizing methadone dose adjustment in patients with opioid use disorder

Introduction

Opioid use disorder is a cause for concern globally. This study aimed to optimize methadone dose adjustments using mixed modeling and machine learning.

Methods

This retrospective study was conducted at Taichung Veterans General Hospital between January 1, 2019, and December 31, 2020. Overall, 40,530 daily dosing records and 1,508 urine opiate test results were collected from 96 patients with opioid use disorder. A two-stage approach was used to create a model of the optimized methadone dose. In Stage 1, mixed modeling was performed to analyze the association between methadone dose, age, sex, treatment duration, HIV positivity, referral source, urine opiate level, last methadone dose taken, treatment adherence, and likelihood of treatment discontinuation. In Stage 2, machine learning was performed to build a model for optimized methadone dose.

Results

Likelihood of discontinuation was associated with reduced methadone doses (β = 0.002, 95% CI = 0.000-0.081). Correlation analysis between the methadone dose determined by physicians and the optimized methadone dose showed a mean correlation coefficient of 0.995 ± 0.003, indicating that the difference between the methadone dose determined by physicians and that determined by the model was within the allowable range (p < 0.001).

Conclusion

We developed a model for methadone dose adjustment in patients with opioid use disorders. By integrating urine opiate levels, treatment adherence, and likelihood of treatment discontinuation, the model could suggest automatic adjustment of the methadone dose, particularly when face-to-face encounters are impractical.

Differential effect of cannabis use on opioid agonist treatment outcomes: Exploratory analyses from the OPTIMA study

INTRODUCTION

Conflictual evidence exists regarding the effects of cannabis use on the outcomes of opioid agonist therapy (OAT). In this exploratory analysis, we examined the effect of recent cannabis use on opioid use, craving, and withdrawal symptoms, in individuals participating in a trial comparing flexible buprenorphine/naloxone (BUP/NX) take-home dosing model to witnessed ingestion of methadone.

METHODS

We analyzed data from a multi-centric, pragmatic, 24-week, open label, randomized controlled trial in individuals with prescription-type opioid use disorder (n = 272), randomly assigned to BUP/NX (n = 138) or methadone (n = 134). The study measured last week cannabis and opioid use via timeline-follow back, recorded at baseline and every two weeks during the study. Craving symptoms were measured using the Brief Substance Craving Scale at baseline, and weeks 2, 6, 10, 14, 18 and 22. The study measured opioid withdrawal symptoms via Clinical Opiate Withdrawal Scale at treatment initiation and weeks 2, 4, and 6.

RESULTS

The mean maximum dose taken during the study was 17.3 mg/day (range = 0.5-32 mg/day) for BUP/NX group and 67.7 mg/day (range = 10-170 mg/day) in the methadone group. Repeated measures generalized linear mixed models demonstrated that cannabis use in the last week (mean of 2.3 days) was not significantly associated with last week opioid use (aβ ± standard error (SE) = -0.06 ± 0.04; p = 0.15), craving (aβ ± SE = -0.05 ± 0.08, p = 0.49), or withdrawal symptoms (aβ ± SE = 0.09 ± 0.1, p = 0.36). Bayes factor (BF) for each of the tested models supported the null hypothesis (BF < 0.3).

CONCLUSIONS

The current study did not demonstrate a statistically significant effect of cannabis use on outcomes of interest in the context of a pragmatic randomized-controlled trial. These findings replicated previous results reporting no effect of cannabis use on opioid-related outcomes.

Default mode network mechanisms of repeated transcranial magnetic stimulation in heroin addiction

Repetitive transcranial magnetic stimulation (rTMS) over the left dorsolateral prefrontal cortex (DLPFC) has been shown to reduce cravings in heroin-dependent (HD) individuals, but the mechanisms underlying the anti-craving effects of rTMS are unknown. Abnormalities in the default mode network (DMN) are known to be consistent findings in HD individuals and are involved in cravings. We assessed the effect of rTMS on DMN activity and its relationship to the treatment response. Thirty HD individuals were included in this self-controlled study, and all HD participants received 10-Hz rTMS 7-session during a week. Data for cravings and withdrawal symptoms and resting-state functional magnetic resonance imaging data were collected before and after rTMS treatment. Thirty demographically matched healthy individuals who did not receive rTMS were included as controls. We focused on changes in coupling seeded from the medial prefrontal cortex (MPFC), posterior cingulate cortex (PCC), and bilateral inferior parietal lobe (IPL), which are the core regions of the DMN. The craving and withdrawal symptom score of HD individuals decreased significantly after rTMS treatment. The left IPL-left middle frontal gyrus coupling and the left IPL-right inferior occipital gyrus coupling decreased significantly, and the changes in the left IPL-left middle frontal gyrus coupling were positively correlated with changes in drug-cue induced cravings. rTMS could modulate the coupling between the DMN and executive control network (ECN). Alterations of the left IPL-left middle frontal gyrus coupling may play an important mechanistic role in reducing drug cue-induced cravings.

Repetitive transcranial magnetic stimulation modulates coupling among large-scale brain networks in heroin-dependent individuals: A randomized resting-state functional magnetic resonance imaging study

The abnormal interactions of three key large-scale brain networks (default mode [DMN], salience and executive control [ECN]) were showed underlie dysfunctions in heroin addiction. Repetitive transcranial magnetic stimulation (rTMS) targeting the left dorsolateral prefrontal cortex (DLPFC) is a potential treatment for heroin addiction. It is unclear whether impaired coupling among the large-scale brain networks would be improved by rTMS in treated heroin-dependent individuals. Thirty-five heroin-dependent individuals were included in this sham-controlled, randomized study. The patients received either active or sham rTMS for 1 week. The craving for heroin and resting-state functional magnetic resonance imaging data were collected before and after 1-week rTMS. Twenty-two healthy subjects were included as controls not receiving rTMS. After 1-week rTMS, only the active rTMS group showed a significant decrease in spontaneous and heroin cue-induced craving. The coupling between left DLPFC (a key node of left ECN) and left parahippocampal gyrus (PHG, included in DMN) significantly increased for the active group with a tendency towards that of controls. The coupling between the right precentral gyrus and three key regions included in DMN (posterior cingulate cortex/precuneus and bilateral inferior parietal cortex) significantly decreased for the active group with a tendency towards that of healthy controls. For the active rTMS individuals, the left DLPFC-PHG coupling negatively correlated with the spontaneous craving and the drug cue-induced craving. It suggested that the rTMS could reduce heroin craving, which might be related to the modulation of ECN-DMN coupling. This finding might shed light on the mechanism of rTMS for heroin addiction treatment.

Contingency Management for Patients Receiving Medication for Opioid Use Disorder: A Systematic Review and Meta-analysis

Importance

Medication treatment for opioid use disorder (MOUD) is efficacious, but comorbid stimulant use and other behavioral health problems often undermine efficacy.

Objective

To examine the association of contingency management, a behavioral intervention wherein patients receive material incentives contingent on objectively verified behavior change, with end-of-treatment outcomes for these comorbid behavioral problems.

Data Sources

A systematic search of PubMed, Cochrane CENTRAL, Web of Science, and reference sections of articles from inception through May 5, 2020. The following search terms were used: vouchers OR contingency management OR financial incentives.

Study Selection

Prospective experimental studies of monetary-based contingency management among participants receiving MOUD.

Data Extraction and Synthesis

Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline, 3 independent investigators extracted data from included studies for a random-effects meta-analysis.

Main Outcomes and Measures

Primary outcome was the association of contingency management at end-of-treatment assessments with 6 clinical problems: stimulant use, polysubstance use, illicit opioid use, cigarette smoking, therapy attendance, and medication adherence. Random-effects meta-analysis models were used to compute weighted mean effect size estimates (Cohen d) and corresponding 95% CIs separately for each clinical problem and collapsing across the 3 categories assessing abstinence and the 2 assessing treatment adherence outcomes.

Results

The search identified 1443 reports of which 74 reports involving 10 444 unique adult participants met inclusion criteria for narrative review and 60 for inclusion in meta-analyses. Contingency management was associated with end-of-treatment outcomes for all 6 problems examined separately, with mean effect sizes for 4 of 6 in the medium-large range (stimulants, Cohen d = 0.70 [95% CI, 0.49-0.92]; cigarette use, Cohen d = 0.78 [95% CI, 0.43-1.14]; illicit opioid use, Cohen d = 0.58 [95% CI, 0.30-0.86]; medication adherence, Cohen d = 0.75 [95% CI, 0.30-1.21]), and 2 in the small-medium range (polysubstance use, Cohen d = 0.46 [95% CI, 0.30-0.62]; therapy attendance, d = 0.43 [95% CI, 0.22-0.65]). Collapsing across abstinence and adherence categories, contingency management was associated with medium effect sizes for abstinence (Cohen d = 0.58; 95% CI, 0.47-0.69) and treatment adherence (Cohen d = 0.62; 95% CI, 0.40-0.84) compared with controls.

Conclusions and Relevance

These results provide evidence supporting the use of contingency management in addressing key clinical problems among patients receiving MOUD, including the ongoing epidemic of comorbid psychomotor stimulant misuse. Policies facilitating integration of contingency management into community MOUD services are sorely needed.

Environmental enrichment reduces heroin seeking following incubation of craving in both male and female rats

BACKGROUND

Contemporary treatments for heroin use disorder demonstrate only limited efficacy when the goals are long term abstinence and prevention of relapse. We have demonstrated that environmental enrichment (EE) reduces cue-induced heroin reinstatement in male rats. The present study is an attempt to extend the "anti-relapse" effects of EE to female rats and to periods where incubation of craving is hypothesized to occur.

METHODS

This experiment implemented a 3-phase procedure. In Phase 1, male and female rats were trained to self-administer heroin for 15 days. Phase 2 consisted of a 3- or 15-day forced abstinence (FA) period. In Phase 3 half of the rats were placed into EE and the other half in non-EE housing and subsequently tested for responding in extinction (no heroin or cues) for 15 days followed by a cue-induced reinstatement test.

RESULTS

We found that rats in the 15 days FA condition showed significantly enhanced drug seeking during extinction, irrespective of sex. We also found that EE significantly reduced this effect. During reinstatement, EE significantly reduced drug seeking in male and female rats and in both 3- and 15-day FA groups.

CONCLUSIONS

EE, with or without prolonged FA, effectively reduced heroin seeking in male and female rats. These findings indicate that EE can reduce drug-seeking in males and females and when putative incubation of craving (i.e., prolonged abstinence period) has occurred and suggest that it may aid in the development of future long-term behavioral treatments for individuals at risk for heroin relapse.

Subjective symptoms and serum methadone concentrations: what should guide dose adjustments in methadone maintenance treatment? A naturalistic cohort study from Norway

BACKGROUND

There is little evidence-based guidance on how to optimize methadone dosages among patients with opioid addiction undergoing methadone maintenance treatment (MMT). This study aims to investigate whether self-perceived opioid withdrawal symptoms, adverse effects, and self-reported substance use in patients on MMT are related to serum methadone concentrations and the role that these variables could play in clinical decisions on dose adjustments.

METHODS

This naturalistic prospective cohort study included clinical and laboratory measurements from 83 patients undergoing MMT in outpatient clinics in Bergen, Norway, from May 2017 to January 2020. Information on age, gender, methadone daily doses and serum concentrations, subjective opioid withdrawal symptoms using 16 items Subjective Opioid Withdrawal Scale (SOWS) questionnaire, self-reported adverse effects, and substance use was obtained. Linear mixed modelling was used for analyzing the data.

RESULTS

The mean age of the participants was 45 years, and 33% were women. Almost half reported mild to moderate subjective opioid withdrawal symptoms, and all had experienced at least one subjective adverse effect. The use of at least one substance was reported by 88% of the participants. Serum concentration-to-dose ratios were lower among those who had reported subjective opioid withdrawal symptoms (p) = 0.039). The total SOWS score (p < 0.001); the specific subjective withdrawal symptoms of anxiety (p = 0.004), bone and muscle aches (p = 0.003), restlessness (p = 0.017), and (slightly) shaking (p = 0.046), also use of heroin (p = 0.015) and alcohol (p = 0.011) were associated with lower methadone concentrations. Cannabis use was slightly related to higher methadone concentrations (p = 0.049).

CONCLUSIONS

The findings suggest that the patient's self-perceived symptoms and current clinical condition are related to the serum concentrations of methadone. This interpretation supports dose adjustments based on patient-reported symptoms. In some aberrant cases, measurement of serum concentrations together with other individual assessments may be considered to support the clinical decision.

Pharmacotherapeutic strategies for treating cocaine use disorder-what do we have to offer?

BACKGROUND

Cocaine use contines to be a significant public health problem world-wide. However, despite substantial research efforts, no pharmacotherapies are approved for the treatment of cocaine use disorder (CUD).

ARGUMENT

Studies have identified positive signals for a range of medications for treating CUD. These include long-acting amphetamine formulations, modafinil, topiramate, doxazosin and combined topiramate and mixed amphetamine salts extended-release (MAS-ER). However, valid conclusions about a medication's clinical efficacy require nuanced approaches that take into account behavioural phenotypes of the target population (frequency of use, co-abuse of cocaine and other substances, genetic subgroups, psychiatric comorbidity), variables related to the medication (dose, short-/long-acting formulations, titration speed, medication adherence) and other factors that may affect treatment outcomes. Meta-analyses frequently do not account for these co-varying factors, which contributes to a somewhat nihilistic view on pharmacotherapeutic options for CUD. In addition, the predominant focus on abstinence, which is difficult for most patients to achieve, may overshadow more nuanced therapeutic signals.

CONCLUSION

While there is an emphasis on finding new medications with novel mechanisms of action for treating CUD, currently available medications deserve further investigation based on the existing literature. Evaluating refined metrics of treatment success in well-defined subgroups of patients, and further exploring combination therapies and their synergy with behavioural/psychosocial interventions, are promising avenues to establishing effective therapies for CUD.

Purposeful Fentanyl Use and Associated Factors among Opioid-Dependent People Who Inject Drugs

Introduction: In recent years, opioid-related mortality has increased steadily in the United States. Fentanyl, a synthetic opioid, has been a primary driver of the current wave of overdose-related deaths. Little is known, however, about fentanyl use among opioid-dependent people who inject drugs (PWID). We, therefore, sought to characterize purposeful fentanyl use among PWID. Methods: A cross-sectional survey was administrated to 104 opioid-dependent PWID on methadone who self-reported drug- or sex-related risk behaviors. Participants were recruited between July 2018 and October 2019 from a methadone clinic in New Haven, Connecticut. Multivariable logistic regressions were used to identify independent correlates of purposeful fentanyl use. Results: Overall, 43.2% and 22.1% of the participants reported any (lifetime) or recent (past 30 days) purposeful fentanyl use, respectively. Independent correlates of any purposeful fentanyl use were younger age (aOR= 0.94; p = 0.021), recent daily injection (aOR= 3.52; p = 0.047), recent cocaine use (aOR= 3.54; p = 0.041), and moderate/severe depression (aOR= 3.82; p = 0.028). Independent correlates of recent purposeful fentanyl use were moderate/severe depression (aOR= 10.94; p = 0.031), recently sharing injection equipment (aOR= 2.96; p = 0.044), and recently engaging in transactional sex (aOR= 3.60; p = 0.026). Conclusions: These findings indicate that opioid-dependent PWID on methadone remain at increased risk for overdose given the high prevalence of ongoing purposeful fentanyl exposure. Interventions to reduce the harms associated with fentanyl use should target young PWID and active fentanyl users, with an emphasis on achieving adequate methadone dosage and screening and treating depression in methadone-maintained patients who preferentially seek fentanyl.

Evaluating comparative effectiveness of psychosocial interventions adjunctive to opioid agonist therapy for opioid use disorder: A systematic review with network meta-analyses

BACKGROUND

Guidelines recommend that individuals with opioid use disorder (OUD) receive pharmacological and psychosocial interventions; however, the most appropriate psychosocial intervention is not known. In collaboration with people with lived experience, clinicians, and policy makers, we sought to assess the relative benefits of psychosocial interventions as an adjunct to opioid agonist therapy (OAT) among persons with OUD.

METHODS

A review protocol was registered a priori (CRD42018090761), and a comprehensive search for randomized controlled trials (RCT) was conducted from database inception to June 2020 in MEDLINE, Embase, PsycINFO and the Cochrane Central Register of Controlled Trials. Established methods for study selection and data extraction were used. Primary outcomes were treatment retention and opioid use (measured by urinalysis for opioid use and opioid abstinence outcomes). Odds ratios were estimated using network meta-analyses (NMA) as appropriate based on available evidence, and in remaining cases alternative approaches to synthesis were used.

RESULTS

Seventy-two RCTs met the inclusion criteria. Risk of bias evaluations commonly identified study limitations and poor reporting with regard to methods used for allocation concealment and selective outcome reporting. Due to inconsistency in reporting of outcome measures, only 48 RCTs (20 unique interventions, 5,404 participants) were included for NMA of treatment retention, where statistically significant differences were found when psychosocial interventions were used as an adjunct to OAT as compared to OAT-only. The addition of rewards-based interventions such as contingency management (alone or with community reinforcement approach) to OAT was superior to OAT-only. Few statistically significant differences between psychosocial interventions were identified among any other pairwise comparisons. Heterogeneity in reporting formats precluded an NMA for opioid use. A structured synthesis was undertaken for the remaining outcomes which included opioid use (n = 18 studies) and opioid abstinence (n = 35 studies), where the majority of studies found no significant difference between OAT plus psychosocial interventions as compared to OAT-only.

CONCLUSIONS

This systematic review offers a comprehensive synthesis of the available evidence and the limitations of current trials of psychosocial interventions applied as an adjunct to OAT for OUD. Clinicians and health services may wish to consider integrating contingency management in addition to OAT for OUD in their settings to improve treatment retention. Aside from treatment retention, few differences were consistently found between psychosocial interventions adjunctive to OAT and OAT-only. There is a need for high-quality RCTs to establish more definitive conclusions.

TRIAL REGISTRATION

PROSPERO registration CRD42018090761.

Abstinence-reinforcing contingency management improves HIV viral load suppression among HIV-infected people who use drugs: A randomized controlled trial

BACKGROUND

HIV-infected people who use drugs (PWUD) have poor HIV outcomes. Few studies tested interventions to improve HIV outcomes among PWUD. Abstinence-reinforcing contingency management (CM) reduces drug use and could also improve HIV outcomes.

METHODS

From 2012-2017, we conducted a randomized controlled trial testing whether a 16-week abstinence-reinforcing CM intervention improved HIV viral load (VL) among HIV-infected adults using opioids or cocaine. In the CM intervention, drug-free urines led to escalating value of vouchers ($2.50-$80/voucher, $1320 total maximum). In intention-to-treat mixed-effects linear and logistic regression analyses, we examined whether the CM intervention improved log₁₀ VL (primary outcome), abstinence and antiretroviral adherence (secondary outcomes).

RESULTS

Thirty-seven participants were randomized to the CM intervention and 36 to control. Median age was 49.2 years; most were male (61.6%) and non-Hispanic black (46.6%). In CM (vs. control) participants, mean reduction in log₁₀ VL was greater (-0.16 log₁₀ VL copies/mL per 4-week period; 95% CI: -0.29 to -0.03, p < 0.05). Over 16 weeks, CM participants had a mean reduction of 0.64 copies/mL in log₁₀ VL greater than control participants. The CM intervention was not significantly associated with abstinence or adherence.

CONCLUSIONS

This is the first study to demonstrate improvements in HIV VL via an abstinence-reinforcing CM intervention. Because the CM intervention did not significantly affect abstinence or adherence, the mechanism of its effect is unclear. To end the HIV epidemic, innovative strategies must address individuals with poor HIV outcomes. Abstinence-reinforcing CM may be one potential strategy to improve HIV outcomes among a select group of PWUD.

Effects of time-based administration of abstinence reinforcement targeting opiate and cocaine use

Polydrug use is a common problem among patients in opioid-substitution treatment. Polydrug use has been reduced by administering abstinence-reinforcement contingencies in a sequence, such that a single drug is targeted until abstinence is achieved, and then an additional drug is targeted. The present study examined effects of administering abstinence-reinforcement contingencies sequentially based on time rather than on achieved abstinence. Participants accessed paid work (about $10/hr maximum) in the Therapeutic Workplace by providing urine samples 3 times per week. The urine samples were tested for opiates and cocaine. During an induction period, participants earned maximum pay independent of drug abstinence. Then, maximum pay depended upon urine samples that were negative for opiates. Two weeks later, maximum pay depended upon urine samples that were negative for both opiates and cocaine. Opiate and cocaine abstinence increased following administration of the respective contingencies. The time-based administration of abstinence reinforcement increased opiate and cocaine abstinence.

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.

Acceptability and willingness to pay for contingency management interventions among parents of young adults with problematic opioid use

BACKGROUND

There is a need for new research addressing the cost prohibitive nature of maintaining contingency management (CM) in community settings. While researchers propose managed care as an option to support costs, there is no research on self-pay models. To inform such research, it is important first to understand client willingness to pay for CM services. We examine acceptability and willingness to pay for CM services among parents with and without young adult children with problematic opioid use.

METHODS

A web-based survey was administered to a sample of parents of adult children ages 18-35 with (target sample) and without (comparison sample) a history of problematic opiate use.

RESULTS

One hundred thirty parents participated (n_target = 30; n_comparison = 100) and were predominately white, college educated, and of higher income. Findings showed a high proportion of participants had positive opinions of using incentives for substance use treatment and would consider incentive-based treatments for their child. Most participants reported they would be willing to pay for CM at levels consistent with amounts used in efficacious programs but expressed worry that incentives would be used to buy drugs. Most participants reported this worry would be eased if incentives were delivered via reloadable gift cards and if incentives were only delivered during periods of abstinence.

CONCLUSIONS

This is the first study to examine parent perceptions of incentives and acceptability and willingness to pay for CM services. Results suggest self-pay models for disseminating CM to young adults with problematic opioid use may be an option.

Craving in Opioid Use Disorder: From Neurobiology to Clinical Practice

Opioid use disorder (OUD) is a major public health issue that has reached epidemic levels in some parts of the world. It is a chronic and complex neurobiological disease associated with frequent relapse to drug taking. Craving, defined as an overwhelmingly strong desire or need to use a drug, is a central component of OUD and other substance use disorders. In this review, we describe the neurobiological and neuroendocrine pathways that underpin craving in OUD and also focus on the importance of assessing and treating craving in clinical practice. Craving is strongly associated with patients returning to opioid misuse and is therefore an important treatment target to reduce the risk of relapse and improve patients' quality of life. Opioid agonist therapies (OAT), such as buprenorphine and methadone, can significantly reduce craving and relapse risk, and it is essential that patients are treated optimally with these therapies. There is also evidence to support the benefits of non-pharmacological approaches, such as cognitive behavioral therapy and mindfulness-based interventions, as supplementary treatments to opioid agonist therapies. However, despite the positive impact of these treatments on craving, many OUD patients continue to suffer with negative affect and dysphoria. There is a clear need for further studies to progress our understanding of the neurobiological basis of craving and addiction and to identify novel therapeutic strategies as well as to optimize the use of existing treatments to improve outcomes for the growing numbers of patients affected by OUD.

Concurrent drug use among methadone maintenance patients in mountainous areas in northern Vietnam

OBJECTIVES

With the rise in methadone maintenance therapy (MMT) for drug users in Vietnam, there has been growing interest in understanding if and how often MMT patients engage in concurrent illicit drug use while on methadone therapy in various settings. This study examined factors associated with concurrent opioid use among patients on MMT in a mountainous area in Vietnam.

SETTING

One urban and one rural MMT clinics in Tuyen Quang province.

PARTICIPANTS

Survey participants consisted of patients who were taking MMT at the selected study sites. A convenience sampling approach was used to recruit the participants.

PRIMARY AND SECONDARY OUTCOME MEASURES

Participants were asked a series of questions about their socioeconomic status, current alcohol and tobacco use, health problems (measured by the EuroQol-Five Dimension-Five Level instrument), psychological distress (measured by Kessler score), and factors associated with current and/or previous drug use. Regression models were used to determine factors associated with concurrent drug use among MMT patients.

RESULTS

Among the 241 male MMT patients included in the study, 13.4% reported concurrent opioid use. On average, the longer patients had been enrolled in MMT, the less likely they were to concurrently use drugs. Conversely, patients with higher levels of psychological distress were more likely to engage in concurrent drug use while on MMT.

CONCLUSION

Longer duration of MMT was significantly correlated with reduced illicit drug use among participants. Higher levels of psychological distress were associated with increased use of illicit drugs among MMT patients. Regardless of distance, long-term MMT is still effective and should be expanded in mountainous areas.

National survey of methadone prescribing for maintenance treatment: ‘opiophobia’ among substance misuse services?

Aims and Method

The aims of this study were to describe the characteristics of substance misuse services prescribing methadone for maintenance treatment of opioid dependence and to determine the average daily doses of methadone prescribed across England. A postal questionnaire survey of all substance misuse treatment centres in England was carried out.

Results

A total of 298 treatment centres were identified and contacted, 212 of which responded to the survey (response rate of 71%). Of these, 157 were prescribing methadone for maintenance treatment; the majority (71%) were community-based and 125 centres had doctors attached. The most common formulation of methadone prescription was oral methadone mixture (152 centres, 97%). The mean daily dose of methadone prescribed was 47 mg. Surprisingly, 37 (24%) of the respondents felt that methadone maintenance treatment should be time-limited and 21 teams (13%) stated that patients should receive only drug substitution and no psychosocial interventions.

Clinical Implications

There is currently a move among substance misuse services towards community-based treatment. In our survey, the mean daily dose of methadone prescribed was less than the dosage recommended by the Department of Health. This suggests that specialist addiction services are continuing to underprescribe heroin substitutes. The inadequate understanding of some of the respondents of the basic principles of methadone maintenance treatment also raises concerns, and highlights the need for further training and education.

What works in drug addiction?

Treatment of illicit drug dependence typically involves a combination of pharmacotherapy and psychosocial interventions. Efficacy research supports methadone maintenance in opiate dependence. There is less evidence to support buprenorphine (an opiate receptor partial agonist), lofexidine (an α2-adrenoreceptor agonist) and naltrexone (an opiate receptor antagonist). Evidence for the effectiveness of detoxification, which one of the most widely used treatments, is poor. Of the psychosocial interventions, reasonable evidence exists for the effectiveness of motivational interviewing. Other psychosocial treatments have rarely been compared with no or minimal contact conditions in randomised trials, and their reported effectiveness is often weak. Residential treatments are not demonstrably more effective than community programmes.

Preventing blood-borne virus infection in people who inject drugs in the UK: systematic review, stakeholder interviews, psychosocial intervention development and feasibility randomised controlled trial

BACKGROUND

Opioid substitution therapy and needle exchanges have reduced blood-borne viruses (BBVs) among people who inject drugs (PWID). Some PWID continue to share injecting equipment.

OBJECTIVES

To develop an evidence-based psychosocial intervention to reduce BBV risk behaviours and increase transmission knowledge among PWID, and conduct a feasibility trial among PWID comparing the intervention with a control.

DESIGN

A pragmatic, two-armed randomised controlled, open feasibility trial. Service users were Steering Group members and co-developed the intervention. Peer educators co-delivered the intervention in London.

SETTING

NHS or third-sector drug treatment or needle exchanges in Glasgow, London, Wrexham and York, recruiting January and February 2016.

PARTICIPANTS

Current PWID, aged ≥ 18 years.

INTERVENTIONS

A remote, web-based computer randomisation system allocated participants to a three-session, manualised, psychosocial, gender-specific group intervention delivered by trained facilitators and BBV transmission information booklet plus treatment as usual (TAU) (intervention), or information booklet plus TAU (control).

MAIN OUTCOME MEASURES

Recruitment, retention and follow-up rates measured feasibility. Feedback questionnaires, focus groups with participants who attended at least one intervention session and facilitators assessed the intervention's acceptability.

RESULTS

A systematic review of what works to reduce BBV risk behaviours among PWID; in-depth interviews with PWID; and stakeholder and expert consultation informed the intervention. Sessions covered improving injecting technique and good vein care; planning for risky situations; and understanding BBV transmission. Fifty-six per cent (99/176) of eligible PWID were randomised: 52 to the intervention group and 47 to the control group. Only 24% (8/34) of male and 11% (2/18) of female participants attended all three intervention sessions. Overall, 50% (17/34) of men and 33% (6/18) of women randomised to the intervention group and 47% (14/30) of men and 53% (9/17) of women randomised to the control group were followed up 1 month post intervention. Variations were reported by location. The intervention was acceptable to both participants and facilitators. At 1 month post intervention, no increase in injecting in 'risky' sites (e.g. groin, neck) was reported by participants who attended at least one session. PWID who attended at least one session showed a trend towards greater reduction in injecting risk behaviours, a greater increase in withdrawal planning and were more confident about finding a vein. A mean cost of £58.17 per participant was calculated for those attending one session, £148.54 for those attending two sessions and £270.67 for those attending all three sessions, compared with £0.86 in the control group. Treatment costs across the centres vary as a result of the different levels of attendance, as total session costs are divided by attendees to obtain a cost per attendee. The economic analysis suggests that a cost-effectiveness study would be feasible given the response rates and completeness of data. However, we have identified aspects where the service use questionnaire could be abbreviated given the low numbers reported in several care domains. No adverse events were reported.

CONCLUSIONS

As only 19% of participants attended all three intervention sessions and 47% were followed up 1 month post intervention, a future definitive randomised controlled trial of the intervention is not feasible. Exposure to information on improving injecting techniques did not encourage riskier injecting practices or injecting frequency, and benefits were reported among attendees. The intervention has the potential to positively influence BBV prevention. Harm reduction services should ensure that the intervention content is routinely delivered to PWID to improve vein care and prevent BBVs.

FUTURE WORK

The intervention did not meet the complex needs of some PWID, more tailoring may be needed to reach PWID who are more frequent injectors, who are homeless and female.

LIMITATIONS

Intervention delivery proved more feasible in London than other locations. Non-attendance at the York trial site substantially influenced the results.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN66453696 and PROSPERO 014:CRD42014012969.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 72. See the NIHR Journals Library website for further project information.

Contingency Management interventions for non-prescribed drug use during treatment for opiate addiction: A systematic review and meta-analysis

BACKGROUND AND AIMS

Use of non-prescribed drugs during treatment for opiate addiction reduces treatment success, creating a need for effective interventions. This review aimed to assess the efficacy of contingency management, a behavioural treatment that uses rewards to encourage desired behaviours, for treating non-prescribed drug use during opiate addiction treatment.

METHODS

A systematic search of the databases Embase, PsychInfo, PsychArticles and Medline from inception to March 2015 was performed. Random effects meta-analysis tested the use of contingency management to treat the use of drugs during opiate addiction treatment, using either longest duration of abstinence (LDA) or percentage of negative samples (PNS). Random effects moderator analyses were performed for six potential moderators: drug targeted for intervention, decade in which the study was carried out, study quality, intervention duration, type of reinforcer, and form of opiate treatment.

RESULTS

The search returned 3860 papers; 22 studies met inclusion criteria and were meta-analysed. Follow-up data was only available for three studies, so all analyses used end of treatment data. Contingency management performed significantly better than control in reducing drug use measured using LDA (d=0.57, 95% CI: 0.42-0.72) or PNS (d=0.41) (95% CI: 0.28-0.54). This was true for all drugs other than opiates. The only significant moderator was drug targeted (LDA: Q=10.75, p=0.03).

CONCLUSION

Contingency management appears to be efficacious for treating most drug use during treatment for opiate addiction. Further research is required to ascertain the full effects of moderating variables, and longer term effects.

Evaluation of a Shared-Care Program for Methadone Treatment of Drug Abuse: An International Perspective

The North Wales (United Kingdom) Shared-Care Program for methadone treatment of drug abuse was evaluated. The program involves shared care, inasmuch as general practitioners, pharmacists, and community drug workers are jointly involved in the methadone treatment of persons with drug abuse. Evaluation aimed to determine the program's (a) extent of use, (b) impact on patients, (c) positive and negative consequences for methadone reduction or discontinuation, and (d) advantages and disadvantages. Results suggested that the program is successful but identified targets for future improvement.

Brain white matter integrity in heroin addicts during methadone maintenance treatment is related to relapse propensity

INTRODUCTION

Cognitive deficits caused by heroin-induced white matter (WM) impairments hinder addicts' engagement in and benefit from treatment. The predictive value of WM integrity in heroin addicts during methadone maintenance treatment (MMT) for future relapse is unclear.

METHODS

Forty-eight MMT patients were given baseline diffusion tensor imaging scans and divided into heroin relapsers (HR, 25 cases) and abstainers (HA, 23 cases) according to the results of 6-month follow-up. Intergroup comparisons were performed for fractional anisotropy (FA), radial diffusivity (RD), and axial diffusivity (AD). The correlation between diffusion tensor imaging indices and the degree of heroin relapse was analyzed.

RESULTS

Compared with HA group, HR group had reduced FA in the right retrolenticular part, left anterior and posterior limb of internal capsule, bilateral anterior corona radiata, and right external capsule. Three out of the six regions showed increased RD, with no changes in AD. The FA and AD values in the left posterior limb of internal capsule correlated negatively with the heroin-positive urinalysis rate within follow-up.

CONCLUSIONS

Lower WM integrity in MMT patients may add to neurobiological factors associated with relapse to heroin use. Strategies for improving WM integrity provide a new perspective to prevent future relapse to heroin abuse.

Predicting subsequent relapse by drug-related cue-induced brain activation in heroin addiction: an event-related functional magnetic resonance imaging study

Abnormal salience attribution is implicated in heroin addiction. Previously, combining functional magnetic resonance imaging (fMRI) and a drug cue-reactivity task, we demonstrated abnormal patterns of subjective response and brain reactivity in heroin-dependent individuals. However, whether the changes in cue-induced brain response were related to relapse was unknown. In a prospective study, we recruited 49 heroin-dependent patients under methadone maintenance treatment, a gold standard treatment (average daily dose 41.8 ± 16.0 mg), and 20 healthy subjects to perform the heroin cue-reactivity task during fMRI. The patients' subjective craving was evaluated. They participated in a follow-up assessment for 3 months, during which heroin use was assessed and relapse was confirmed by self-reported relapse or urine toxicology. Differences between relapsers and non-relapsers were analyzed with respect to the results from heroin-cue responses. Compared with healthy subjects, relapsers and non-relapsers commonly demonstrated significantly increased brain responses during the processing of heroin cues in the mesolimbic system, prefrontal regions and visuospatial-attention regions. However, compared with non-relapsers, relapsers demonstrated significantly greater cue-induced craving and the brain response mainly in the bilateral nucleus accumbens/subcallosal cortex and cerebellum. Although the cue-induced heroin craving was low in absolute measures, the change in craving positively correlated with the activation of the nucleus accumbens/subcallosal cortex among the patients. These findings suggest that in treatment-seeking heroin-dependent individuals, greater cue-induced craving and greater specific regional activations might be related to reward/craving and memory retrieval processes. These responses may predict relapse and represent important targets for the development of new treatment for heroin addiction.

Familial expressed emotion among heroin addicts in methadone maintenance treatment: does it matter?

BACKGROUND

Expressed emotion (EE) is the quality of the atmosphere between a relative and a family member with mental illness. Substantial research has focused on the relationship between the level of EE and the outcomes of mental illness. However, no prior study has explored the role of EE relative to heroin addicts.

AIM

The aims of this study were to investigate the influence of EE on patient outcome in methadone maintenance treatment (MMT) and the relationship between the EE of heroin addicts and other demographic and psychological variables.

METHODS

A total of 117 heroin addicts who entered MMT were enrolled. Each subject underwent a comprehensive interview to record demographic data and drug use history. The Family Emotional Involvement Scale (FEICS), Beck Depression Inventory (BDI), and Beck Anxiety Depression Inventory (BAI) were used at baseline. All subjects were followed for 12 months. The results of monthly urine tests and the treatment retention were recorded for further analysis.

RESULTS

Perceived criticism was correlated with depression (r=0.20, P<0.01). The overall retention rate in 12-month MMT was 54.70%. Lower perceived criticism (OR=1.84, 95% CI=1.20-3.60, P<0.01) and lower depression (OR=1.24, 95% CI=0.65-1.80, P=0.02) predicted longer retention in MMT.

CONCLUSION

EE, especially perceived criticism, has its influences on outcomes among heroin addicts in MMT. This suggested the potential benefits of family therapy among high EE heroin addicts in MMT. Furthermore, the mechanism how EE affects the outcome of MMT needs to be further investigated.

Effect of integrating HIV and addiction care for non-engaging HIV-infected opiate-dependent patients

BACKGROUND

HIV-positive substance dependent patients contribute disproportionally to HIV morbidity and mortality as a result of poor compliance with their HIV treatment. For HIV-positive opiate-dependent patients integrating HIV and addiction care improves HIV morbidity but the effect on addiction morbidity is not known.

AIMS

This study aims to establish if integrating HIV and addiction care has a significant effect on addiction and HIV morbidity for non-engaging HIV-positive opiate-dependent patients.

METHODS

Patients attending the National Drug Treatment Centre who had disengaged from their HIV treatment in St James's Hospital were recruited to receive HIV care integrated into their methadone maintenance programme. Outcome was investigated in terms of urine toxicology (opiates, cocaine, cannabis and amphetamines); adherence to methadone; proportion receiving directly observed antiretroviral therapy; proportion HIV virally suppressed; and the CD4 cell count.

RESULTS

No significant change in substance use or methadone adherence was demonstrated in the 19 recruited participants. There was a significant increase in the proportion receiving directly observed antiretroviral therapy, and in the CD4 cell count.

CONCLUSION

Integration of HIV and addiction care optimises the physical health of non-engaging HIV-positive opiate-dependent patients with no substantial effect on their methadone maintenance programme.

The effects of fixed versus escalating reinforcement schedules on smoking abstinence

Studies indicate that when abstinence is initiated, escalating reinforcement schedules maintain continuous abstinence longer than fixed reinforcement schedules. However, these studies were conducted for shorter durations than most clinical trials and also resulted in larger reinforcer value for escalating participants during the 1st week of the experiment. We tested whether escalating reinforcement schedules maintained abstinence longer than fixed reinforcement schedules in a 12-week clinical trial. Smokers (146) were randomized to an escalating reinforcement schedule, a fixed reinforcement schedule, or a control condition. Escalating reinforcement participants received $5.00 for their first breath carbon monoxide (CO) sample <3 ppm, with a $0.50 increase for each consecutive sample. Fixed reinforcement participants received $19.75 for each breath CO sample <3 ppm. Control participants received payments only for delivering a breath CO sample. Similar proportions of escalating and fixed reinforcement participants met the breath CO criterion at least once. Escalating reinforcement participants maintained criterion breath CO levels longer than fixed reinforcement and control participants. Similar to previous short-term studies, escalating reinforcement schedules maintained longer durations of abstinence than fixed reinforcement schedules during a clinical trial.

Efficacy of contingency management in improving retention and compliance to methadone maintenance treatment: a random controlled study

Background

Compliance with methadone maintenance treatment (MMT) in China is poor.

Objective

To evaluate the effects of adjunctive contingency management (CM) on the efficacy of methadone maintenance treatment (MMT) in patients with opioid dependence.

Hypothesis

A 12-week prize-based contingency management (CM) intervention can increase the retention and compliance of heroin abusers to standardized MMT programs in Shanghai.

Methods

160 heroin-dependent patients from three voluntary MMT clinics in Shanghai were randomly assigned to a treatment as usual group (MMT, n=80) and an intervention group (MMT+CM, n=80). Daily use of methadone was recorded and urine drug tests were conducted weekly during the first 12 weeks and then at week 16, week 20 and week 24.

Results

The 12-week retention rates for the intervention (MMT+CM) and treatment-as-usual (MMT) groups were both quite high: 87.5% and 86.2%, respectively. The average durations of using methadone in the two groups were equal (70 days versus 71 days, respectively). There was a non-significant increase in the mean longest drug-free period (7.4 weeks versus 6.5 weeks) and in the mean number of negative urine tests (7.9 versus 7.6). Secondary analysis of the 24-week outcomes (12 weeks after termination of the adjunctive CM treatment) also found no significant differences between the groups. Among those who remained in the program the severity of addiction as assessed by the Addiction Severity Index decreased dramatically over the 24 weeks but, again, there were no significant differences in the addiction measures between those in the intervention group and those in the treatment-as-usual group.

Conclusion

Prize-based CM is not effective in improving the retention and compliance of heroin abusers to MMT in Shanghai. The main reasons for failure to replicate western studies were the unexpectedly high baseline rates of compliance in this sample (86%) and the relatively weak financial incentives provided by the CM program. CM programs are context dependent so a careful preliminary situational analysis is needed to determine their potential effectiveness at a particular site and to identify the types of incentives (prizes) that will effectively encourage behavioral change in the target participants.

Safe methadone induction and stabilization: report of an expert panel

OBJECTIVES

Methadone is a well-studied, safe, and effective medication when dispensed and consumed properly. However, a number of studies have identified elevated rates of overdose and death in patients being treated with methadone for either addiction or chronic pain. Among patients being treated with methadone in federally certified opioid treatment programs, deaths most often occur during the induction and stabilization phases of treatment. To address this issue, the federal Substance Abuse and Mental Health Services Administration invited the American Society of Addiction Medicine to convene an expert panel to develop a consensus statement on methadone induction and stabilization, with recommendations to reduce the risk of patient overdose or death related to methadone maintenance treatment of addiction.

METHODS

A comprehensive literature search of English-language publications (1979-2011) was conducted via MEDLINE and EMBASE. Methadone Action Group members evaluated the resulting information and collaborated in formulating the consensus statement presented here, which subsequently was reviewed by more than 100 experts in the field.

RESULTS

Published data indicate that deaths during methadone induction occur because the initial dose is too high, the dose is increased too rapidly, or the prescribed methadone interacts with another drug. Therefore, the Methadone Action Group has developed recommendations to help methadone providers avoid or minimize these risks.

CONCLUSIONS

Careful management of methadone induction and stabilization, coupled with patient education and increased clinical vigilance, can save lives in this vulnerable patient population.

Extended-release naltrexone modulates brain response to drug cues in abstinent heroin-dependent patients

Drug cues play an important role in relapse to drug use. Naltrexone is an opioid antagonist that is used to prevent relapse in opioid dependence. Central opioidergic pathways may be implicated in the heightened drug cue-reactivity, but the effects of the opioid receptors' blockade on the brain responses to drug cues in opioid dependence are unknown. To pursue this question, we studied 17 abstinent i.v. heroin users with brain functional magnetic resonance imaging (fMRI) during exposure to visual heroin-related cues and matched neutral images before and 10-14 days after an injection of extended-release naltrexone (XRNTX). Whole brain analysis of variance of fMRI data showed main effect of XRNTX in the medial frontal gyrus, precentral gyrus, cuneus, precuneus, caudate and the amygdala. fMRI response was decreased in the amygdala, cuneus, caudate and the precentral gyrus and increased in the medial frontal gyrus and the precuneus. Higher plasma levels of naltrexone's major metabolite, 6-beta-naltrexol, were associated with larger reduction in the fMRI response to drug cues after XRNTX in the precentral, caudate and amygdala clusters. The present data suggest that XRNTX pharmacotherapy of opioid-dependent patients may, respectively, decrease and potentiate prefrontal and limbic cortical responses to drug cues and that this effect might be related to the XRNTX metabolism. Our findings call for further evaluation of the brain fMRI response to drug-related cues and of the 6-beta-naltrexol levels as potential biomarkers of XRNTX therapeutic effects in patients with opioid dependence.

Correlates of depressive symptoms among alcohol-using methadone maintained adults

BACKGROUND

Alcohol-using clients are considered at great risk for hepatitis and ongoing liver damage. This study explores the correlates of depression among a sample of methadone maintained treatment (MMT) adults in the Los Angeles area, and is part of a larger study on hepatitis health promotion among MMT clients who use alcohol.

OBJECTIVES

We sought to determine correlates of depressive symptoms among moderate and heavy alcohol-using adults enrolled in methadone maintenance.

METHODS

A cross-sectional correlation study was conducted of baseline data from a randomized control trial of adults (N= 189) receiving MMT in Los Angeles. Depressive symptoms were measured with the 10-item short-form CES-D.

RESULTS

Multiple regression analysis revealed that pain and social support were key correlates of depressive symptoms. More pain was associated with higher levels of depressive symptoms (p= .001), while more social support was related to lower depressive symptom severity (p= .001). Having been in sufficiently poor health that a blood transfusion, clotting factors, or an organ transplant was necessary was associated with greater depressive symptomatology, as was having injected drugs in the past month (p= .024).

CONCLUSIONS

The findings from this investigation can aid clinicians in selecting clients to monitor for early signs of depression and encourage early treatment for opioid users with comorbidities.

SCIENTIFIC SIGNIFICANCE

The use of an interdisciplinary team to care for MMT clients, routinely screen for depressive symptoms, and emphasize adequate pain control is indicated.

Higher methadone doses are associated with lower mortality in patients of opioid dependence in Taiwan

Optimal methadone dosage and service profile is challenging in treatment of opioid dependence. This study explores the impact of methadone dosage on the mortality of opioid-dependent patients in methadone maintenance therapy by using a large-scale and continual supervised dosing registry information system. Database of nationwide enrolled opioid-dependent patients at methadone clinics in Taiwan during 2006-2008 was assessed. The relative risk of age, sex, marital status, HIV infection and methadone dosage were analyzed by Cox regression analysis. Among all of the 33,549 recruited patients, the crude mortality rate was 134.78/10,000 person-years, and the standardized mortality ratio was 4.68. A dose-response relationship of higher- vs. lower-dosage groups on the risk of mortality risk was observed (adjusted HR = 0.68, P = 0.016). In further sub-grouping analysis, this trend was more significant in HIV positive patients, in subgroup of patients who continuously staying in MMT, and in subgroup of patients who re-enter MMT. This dosage effect is not significantly seen in patients receiving MMT more than 365 days. Further exploration of other treatment-related factors may be important for understanding the long-term treatment outcome of opioid addiction patients.

A randomized investigation of methadone doses at or over 100 mg/day, combined with contingency management

BACKGROUND

Methadone maintenance for heroin dependence reduces illicit drug use, crime, HIV risk, and death. Typical dosages have increased over the past few years, based on strong experimental and clinical evidence that dosages under 60 mg/day are inadequate and that dosages closer to 100mg/day produce better outcomes. However, there is little experimental evidence for the benefits of exceeding 100 mg/day, or for individualizing methadone dosages. We sought to provide such evidence.

METHODS

We combined individualized methadone dosages over 100 mg/day with voucher-based cocaine-targeted contingency management (CM) in 58 heroin- and cocaine-dependent outpatients. Participants were randomly assigned to receive a fixed dose increase from 70 mg/day to 100mg/day, or to be eligible for further dose increases (up to 190 mg/day, based on withdrawal symptoms, craving, and continued heroin use). All dosing was double-blind. The main outcome measure was simultaneous abstinence from heroin and cocaine.

RESULTS

We stopped the study early due to slow accrual. Cocaine-targeted CM worked as expected to reduce cocaine use. Polydrug use (effect-size h=.30) and heroin craving (effect-size d=.87) were significantly greater in the flexible/high-dose condition than in the fixed-dose condition, with no trend toward lower heroin use in the flexible/high-dose participants.

CONCLUSIONS

Under double-blind conditions, dosages of methadone over 100mg/day, even when prescribed based on specific signs and symptoms, were not better than 100mg/day. This counterintuitive finding requires replication, but supports the need for additional controlled studies of high-dose methadone.

Pharmacokinetic-pharmacodynamic modeling of mood and withdrawal symptoms in relation to plasma concentrations of methadone in patients undergoing methadone maintenance treatment

The aims of the present study were to characterize the relationship between plasma racemic methadone and its enantiomers' concentrations with respect to their pharmacodynamic effects and to investigate the influence of potential covariates on the pharmacodynamic parameters in patients on methadone maintenance treatment (MMT). Eighty-eight regular subjects at the Sheffield Care Trust Substance Misuse Services were studied. Samples of blood and urine were collected before the daily dose of methadone. Blood samples were taken up to 5 hours after dose. Total plasma concentrations of (RS)-methadone and total and unbound plasma concentrations of both enantiomers were measured by liquid chromatography-mass spectrometry. The Total Mood Disturbance Score (TMDS), the Objective Opioid Withdrawal Scale (OOWS), and the Subjective Opioid Withdrawal Scale (SOWS) were used as measures of mood and withdrawal. Population pharmacokinetic/pharmacodynamic analysis and subsequent multiple regression analysis were used to determine the factors influencing the pharmacodynamic effects of methadone. Significant decreases (P ≤ 0.04) were observed in the scores for the TMDS, SOWS, and OOWS for 5 hours after methadone dosage. The TMDS had returned to baseline by 10 hours after dose (P = 0.98), at which time the SOWS remained significantly below baseline (P = 0.001). Multiple regression analysis revealed that 33% of the overall variation in unbound (R)-methadone EC50 was explained by 3 variables, namely CYP3A activity (9%), age (16%), and sex (8%). Age also accounted for 8% and 9% of the variation in total (rac)- and (R)-methadone EC50. The present study has confirmed that the duration of mood change in the present study was shorter than the effect of methadone in stabilizing withdrawal symptoms. Thus, it is likely that a once-daily dose of methadone, albeit effective for preventing withdrawal, may not be sufficient to improve mood in some patients. Finally, it was established that CYP3A activity, years of dependent use, sex, and age are major determinants of methadone EC50 with respect to TMDS.

Methadone maintenance treatment in China: perceived challenges from the perspectives of service providers and patients

BACKGROUND

China has recently adopted methadone maintenance treatment (MMT) as a national strategy to address the problem of drug abuse and related public health issues such as HIV and HCV infections. However, low enrollment and retention rates suggest that barriers may exist in MMT utilization. This study examined both patients' perceptions and service providers' perceptions of challenges in MMT implementation in China.

METHODS

Four focus groups were conducted in two Chinese cities, Shanghai and Kunming, to explore the perceived and experienced barriers in MMT participation in China. All focus group discussions with participants were audio taped and transcribed. Atlas.ti 5.1 was used to analyze data.

RESULTS

Service providers and patient participants reported positive experiences (e.g. effects of MMT in curbing withdrawal symptoms) but also expressed concerns about side effects and continued heroin use during MMT. They also identified barriers in participating and remaining in MMT, including affordability (fee requirement), acceptability (methadone as a substitution, dose, long-term nature), accommodation and accessibility (inconvenient operation hours, lack of transferability to other MMT clinics during travel) and competition between public health and public security.

CONCLUSIONS

The present findings have implications for reconsidering the current MMT policies and practices in order to improve access, utilization and, ultimately, the effectiveness of MMT in China.

The science and practice of medication-assisted treatments for opioid dependence

This paper briefly reviews the evolution of opioid addiction treatment from humanitarian to scientific and evidence-based, the evidence bases supporting major medication-assisted treatments and adjunctive psychosocial techniques, as well as challenges faced by clinicians and treatment providers seeking to provide those treatments. Attitudes, politics, policy, and financial issues are discussed.

Agonist treatment in opioid use: advances and controversy

Opioid dependence is a chronic relapsing condition which requires comprehensive care; pharmacological agents form the mainstay of its long term treatment. The two most popular approaches are the harm reduction method using agonists and the complete abstinence method using antagonists. Currently, particularly from the harm minimization perspective and the low feasibility of an abstinence based approach, there is an increasing trend toward agonist treatment. The use of buprenorphine has gained popularity in view of its safety profile and the availability of the buprenorphine-naloxone combination has made it popular as a take-home treatment. This review outlines the pharmacological advances and controversies in this area.

Addiction treatment-related employment barriers: the impact of methadone maintenance

Employment is commonly upheld as an important outcome of addiction treatment. To explore this attribution, we assessed whether treatment enrollment predicts employment initiation among participants enrolled in a community-recruited Canadian cohort of people who inject drugs (IDU; N = 1,579). Survival analysis initially found no association between addiction treatment enrollment and employment initiation. However, when methadone maintenance therapy (MMT) was separated from other treatment modalities, non-MMT treatment positively predicted employment transitions, whereas MMT was negatively associated with employment initiation. Subanalyses examining transitions into temporary, informal, and under-the-table income generation echo these results. Findings suggest that individual factors impacting employment transitions may systematically apply to MMT clients and that, in this setting, the impact of treatment on employment outcomes is contingent on treatment type and design. Treatment-specific differences underscore the need to expand low-threshold MMT, explore MMT alternatives, and evaluate the impact of treatment design on the social and economic activity of IDU.

Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence

BACKGROUND

Maintenance treatments are effective in retaining patients in treatment and suppressing heroin use. Questions remain regarding the efficacy of additional psychosocial services.

OBJECTIVES

To evaluate the effectiveness of any psychosocial plus any agonist maintenance treatment versus standard agonist treatment for opiate dependence

SEARCH STRATEGY

We searched the Cochrane Drugs and Alcohol Group trials register (June 2011), Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6, 2011), PUBMED (1996 to 2011); EMBASE (January 1980 to 2011); CINAHL (January 2003 to 2011); PsycINFO (1985 to 2003) and reference list of articles.

SELECTION CRITERIA

Randomised controlled trials and controlled clinical trial comparing any psychosocial plus any agonist with any agonist alone for opiate dependence.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality quality and extracted data.

MAIN RESULTS

35 studies, 4319 participants, were included. These studies considered thirteen different psychosocial interventions. Comparing any psychosocial plus any maintenance pharmacological treatment to standard maintenance treatment, results do not show benefit for retention in treatment, 27 studies, 3124 participants, RR 1.03 (95% CI 0.98 to 1.07), abstinence by opiate during the treatment, 8 studies, 1002 participants, RR 1.12 (95% CI 0.92 to 1.37), compliance, three studies, MD 0.43 (95% CI -0.05 to 0.92), psychiatric symptoms, 3 studies, MD 0.02 (-0.28 to 0.31), depression, 3 studies, MD -1.70 (95% CI -3.91 to 0.51) and results at the end of follow up as number of participants still in treatment, 3 studies, 250 participants, RR 0.90 (95% CI 0.77 to 1.07) and participants abstinent by opioid, 3 studies, 181 participants, RR 1.15 (95% CI 0.98 to 1.36). Comparing the different psychosocial approaches, results are never statistically significant for all the comparisons and outcomes.

AUTHORS' CONCLUSIONS

For the considered outcomes, it seems that adding any psychosocial support to standard maintenance treatments do not add additional benefits. Data do not show differences also for contingency approaches, contrary to all expectations. Duration of the studies was too short to analyse relevant outcomes such as mortality. It should be noted that the control intervention used in the studies included in the review on maintenance treatments, is a program that routinely offers counselling sessions in addition to methadone; thus the review, actually, did not evaluate the question of whether any ancillary psychosocial intervention is needed when methadone maintenance is provided, but the narrower question of whether a specific more structured intervention provides any additional benefit to a standard psychosocial support. These interventions probably can be measured and evaluated by employing diverse criteria for evaluating treatment outcomes, aimed to rigorously assess changes in emotional, interpersonal, vocational and physical health areas of life functioning.

Effects of a randomized contingency management intervention on opiate abstinence and retention in methadone maintenance treatment in China

AIMS

Methadone maintenance treatment has been made available in China in response to the rapid spread of human immunodeficiency virus (HIV), but high rates of dropout and relapse are problematic. The aim of this study was to apply and test if a contingency management (or motivational incentives) intervention can improve treatment retention and reduce drug use.

DESIGN

Random assignment to usual care with (n = 160) or without (n = 159) incentives during a 12-week trial. Incentives participants earned draws for a chance to win prizes on two separate tracks targeting opiate-negative urine sample or consecutive attendance; the number of draws increased with continuous abstinence or attendance.

SETTING

Community-based methadone maintenance clinics in Shanghai and Kunming.

PARTICIPANTS

The sample was 23.8% female, mean age was 38, mean years of drug use was 9.4 and 57.8% had injected drugs in the past 30 days.

MEASUREMENTS

Treatment retention and negative drug urine.

FINDINGS

Relative to the treatment-as-usual (control) group, better retention was observed among the incentive group in Kunming (75% versus 44%), but no difference was found in Shanghai (90% versus 86%). Submission of negative urine samples was more common among the incentive group than the usual care (74% versus 68% in Shanghai, 27% versus 18% in Kunming), as was the longest duration of sustained abstinence (7.7 weeks versus 6.5 in Shanghai, 2.5 versus 1.6 in Kunming). The average total prize amount was 371 Yuan (or $55) per participant (527 for Shanghai versus 216 in Kunming).

CONCLUSIONS

Contingency management improves treatment retention and drug abstinence in methadone maintenance treatment clinics in China, although there can be considerable site differences in magnitude of effects.

A qualitative study exploring the reason for low dosage of methadone prescribed in the MMT clinics in China

OBJECTIVES

Dosage of methadone maintenance therapy (MMT) is an important factor influencing retention in methadone treatment. MMT clients in China received lower dosages of methadone compared with those provided in other countries. The objective of this study is to elucidate the reason for the low methadone dosage prescribed in MMT clinics in China.

METHODS

Twenty-eight service providers were recruited from the MMT clinics in Zhejiang and Jiangxi Provinces, China. Qualitative in-depth interviews were conducted to ascertain the procedure for prescribing methadone in the MMT clinics.

RESULTS

The average dosage prescribed in the 28 clinics was 35 mg/person/day. Four major themes resulting in low dosage of methadone were identified: (1) the service providers fear the liability resulting from large doses of methadone in combination with other substances which might result in overdose fatalities, (2) lack of understanding of harm reduction which resulted in low acceptance of the long term maintenance treatment approach, (3) break-down in communication between clients and service providers about dosage adjustment, and (4) dosage reduction is perceived by most service providers as an effective way to treat the side-effects associated with MMT.

CONCLUSIONS

The findings of the study highlighted the necessity to formulate clear guidelines concerning individualized dosage management and to improve training among service providers' in MMT clinics in China.

Methadone maintenance dosing guideline for opioid dependence, a literature review

To date, methadone dosing is still an issue of debate and controversy among clinicians who are involved in methadone maintenance programs. The authors conducted a literature review to update clinicians about this issue and provide recommendations for proper methadone dosing. Studies eligible for inclusion in the review were retrieved from the PubMed database by searching for reports published between 1990 and September 2008 using the major medical subject headings Methadone (all fields) and dose. Only articles written in English were included. Additional reports were identified from the reference lists of retrieved articles and by manual review of the tables of contents of journals on drug of abuse included in the psychiatry and substance abuse subject category listing 2008 of the Journal Citation Reports. Abstracts of medical meetings were excluded. Twenty-four articles were included in the review. Twelve are randomized, controlled, or double-blind clinical trials, 10 are non-randomized and observational studies, and 2 are meta-analyses. Currently, the consensus is to have a goal for methadone dosing in the range of 60 to 100 mg daily. For patients who continue to use illicit opiates while prescribed this dose range, clinicians may consider doses greater than 100 mg daily. However, this is not the current consensus but rather is based on the limited promising data the authors have; it could be considered if the benefits outweigh the risks for some patients.