Psychosocial factors in outcome in two opiate addiction treatments

High perceived stress in patients on opioid agonist therapies during rapid transitional response to the COVID-19 pandemic in Ukraine

Background

The COVID-19 pandemic resulted in marked disruptions in healthcare delivery in Ukraine related to emergency guidance in response to treating opioid use disorder (OUD). Patients with OUD, a group with high levels of comorbid medical and psychiatric disorders, and prescribed opioid agonist therapies (OAT) were rapidly shifted to take-home dosing if they were deemed clinically stable. The impact of these shifts on patient stress and related substance use during the pandemic, however, is unknown.

Methods

In early May 2020, 269 randomly selected OAT patients in Ukraine were surveyed to assess their stress level and substance use using the validated Perceived Stress Scale and examined correlates of severe perceived stress.

Results

Overall, 195 (72.5%) met criteria for moderate to severe levels of stress, which was independently correlated with having started OAT within the past 12 months (aOR: 1.33; 95%CI: 1.15-1.55), living in a large metropolitan area (aOR: 1.31; 95%CI: 1.18-1.46), having been asked by others to share their medication (aOR: 1.13; 95%CI: 1.02-1.25), and having an increase of over 10 min in transportation time to get to treatment (aOR: 1.16; 95%CI: 1.04-1.29). Twenty seven (10%) patients felt at high risk of relapse, while 24 (8.9%) patients reported purchasing drugs.

Conclusion

During a time of great uncertainty soon after emergency guidance to the COVID-19 pandemic, there was extraordinary high levels of perceived stress reported. In response to emergency guidance, OAT patients should be screened for perceived stress and certain subgroups should be targeted for additional psychosocial support.

Stress and opioid use disorder: A systematic review

Medication assisted treatment (MAT) is highly effective in reducing illicit opioid use and preventing overdose in individuals with opioid use disorder (OUD); however, treatment retention of patients engaged in MAT is a significant clinical concern. The experience of stress may contribute to a decision to drop out of treatment. The current study is a systematic review conducted across multiple databases of empirical studies on primary appraisal of stress and its relationship to opioid craving, opioid use, and OUD treatment outcomes. Primary appraisal of stress is defined as an explicit inquiry into individual perception of feeling stressed using a self-report measure administered in laboratory, clinical, or naturalistic environment. A total of 21 included studies were organized into three categories: observed stress, experimentally-induced stress, and stress-focused interventions. Appraised stress was generally associated with greater craving, but associations with opioid use and treatment retention were mixed. All but one study included MAT samples and every study sample included some form of drug counseling. These findings suggest that individuals experience considerable stress in spite of receiving standard treatment for OUD. Psychopharmacological interventions targeting stress were promising, but no behavioral interventions specific to stress management were found. The preliminary results with clonidine and lofexidine targeting stress in individuals with OUD warrant further studies. To better understand the impact of stress in OUD, future research should consider using repeated assessment of stress in the context of daily life. Utilization of behavioral treatments specifically targeting stress could have benefits in improving OUD outcomes.

Oral naltrexone maintenance treatment for opioid dependence

BACKGROUND

Research on clinical application of oral naltrexone agrees on several things. From a pharmacological perspective, naltrexone works. From an applied perspective, the medication compliance and the retention rates are poor.

OBJECTIVES

To evaluate the effects of naltrexone maintenance treatment versus placebo or other treatments in preventing relapse in opioid addicts after detoxification.

SEARCH STRATEGY

We searched: Cochrane Central Register of Controlled Trials (CENTRAL - The Cochrane Library issue 6 2010), PubMed (1973- June 2010), CINAHL (1982- June 2010). We inspected reference lists of relevant articles and contacted pharmaceutical producers of naltrexone, authors and other Cochrane review groups.

SELECTION CRITERIA

All randomised controlled clinical trials which focus on the use of naltrexone maintenance treatment versus placebo, or other treatments to reach sustained abstinence from opiate drugs

DATA COLLECTION AND ANALYSIS

Three reviewers independently assessed studies for inclusion and extracted data. One reviewer carried out the qualitative assessments of the methodology of eligible studies using validated checklists.

MAIN RESULTS

Thirteen studies, 1158 participants, met the criteria for inclusion in this review.Comparing naltrexone versus placebo or no pharmacological treatments, no statistically significant difference were noted for all the primary outcomes considered. The only outcome statistically significant in favour of naltrexone is re incarceration, RR 0.47 (95%CI 0.26-0.84), but results come only from two studies. Considering only studies were patients were forced to adherence a statistical significant difference in favour of naltrexone was found for retention and abstinence, RR 2.93 (95%CI 1.66-5.18).Comparing naltrexone versus psychotherapy, in the two considered outcomes, no statistically significant difference was found in the single study considered.Naltrexone was not superior to benzodiazepines and to buprenorphine for retention and abstinence and side effects. Results come from single studies.

AUTHORS' CONCLUSIONS

The findings of this review suggest that oral naltrexone did not perform better than treatment with placebo or no pharmacological agent with respect to the number of participants re-incarcerated during the study period. If oral naltrexone is compared with other pharmacological treatments such as benzodiazepine and buprenorphine, no statistically significant difference was found. The percentage of people retained in treatment in the included studies is however low (28%). The conclusion of this review is that the studies conducted have not allowed an adequate evaluation of oral naltrexone treatment in the field of opioid dependence. Consequently, maintenance therapy with naltrexone cannot yet be considered a treatment which has been scientifically proved to be superior to other kinds of treatment.

Oral naltrexone maintenance treatment for opioid dependence

BACKGROUND

Research on the clinical application of oral naltrexone agrees on several things. From a pharmacological perspective, naltrexone works. From an applied perspective, however, the medication compliance and the retention rates are very poor.

OBJECTIVES

To evaluate the effects of naltrexone maintenance treatment versus placebo or other treatments in preventing relapse in opioid addicts after detoxification.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL - The Cochrane Library issue 6 2010), PubMed (1973- June 2010), CINAHL (1982- June 2010). We inspected reference lists of relevant articles and we contacted pharmaceutical producers of naltrexone, authors and other Cochrane review groups.

SELECTION CRITERIA

All randomised and controlled clinical trials which focus on the use of naltrexone maintenance treatment versus placebo, or other treatments to reach sustained abstinence from opiate drugs

DATA COLLECTION AND ANALYSIS

Three reviewers independently assessed studies for inclusion and extracted data. One reviewer carried out the qualitative assessments of the methodology of eligible studies using validated checklists.

MAIN RESULTS

Thirteen studies, 1158 participants, met the criteria for inclusion in this review.Comparing naltrexone versus placebo or no pharmacological treatments, no statistically significant difference were noted for all the primary outcomes considered. The only outcome statistically significant in favour of naltrexone is re incarceration, RR 0.47 (95%CI 0.26-0.84), but results come only from two studies.Comparing naltrexone versus psychotherapy, in the two considered outcomes, no statistically significant difference was found in the single study considered.Naltrexone was not superior to benzodiazepines and to buprenorphine for retention and abstinence and side effects. Results come from single studies.

AUTHORS' CONCLUSIONS

The findings of this review suggest that oral naltrexone did not perform better than treatment with placebo or no pharmacological agent with respect to the number of participants re-incarcerated during the study period. If oral naltrexone is compared with other pharmacological treatments such as benzodiazepine and buprenorphine, no statistically significant difference was found. The percentage of people retained in treatment in the included studies is however low (28%). The conclusion of this review is that the studies conducted have not allowed an adequate evaluation of oral naltrexone treatment in the field of opioid dependence. Consequently, maintenance therapy with naltrexone cannot yet be considered a treatment which has been scientifically proved to be superior to other kinds of treatment.

Gender differences in sense of coherence, perceived social support, and negative emotions among drug-abstinent israeli inmates

This study examines gender differences in the sense of coherence, perceived social support, and negative emotions among drug-abstinent Israeli inmates. One hundred nineteen inmates have participated in this study (65 men and 54 women). The findings indicate that among female inmates, abstinence of more than a year is related to a decrease in sense of coherence and to an increase in their perceived friend support. In contrast, among male inmates, abstinence of more than a year is related to an increase in sense of coherence and no change at all in their perceived friend support. In addition, hostility level is lower and sense of coherence is higher when the length of abstinence exceeds a year among male inmates. In contrast, among female inmates hostility level is higher when the sense of coherence is lower, without any connection to the length of abstinence. The implications of these findings to treatment intervention are discussed.

The galanin-3 receptor antagonist, SNAP 37889, reduces operant responding for ethanol in alcohol-preferring rats

BACKGROUND/OBJECTIVE

The galanin-3 receptor (GALR3) subtype has been identified as having a role in both feeding behaviour and the regulation of emotional states including anxiety. Despite the evidence for an association between galanin and alcohol, the current study is the first to explore the direct role of GALR3 in this context. The present study investigated the potential of the novel selective GALR3 antagonist, SNAP 37889, to reduce anxiety-like behaviour and voluntary ethanol consumption in the iP (alcohol-preferring) rat. This was achieved through a number of behavioural paradigms testing for anxiety, along with the operant self-administration model.

RESULTS

Overall, male iP rats treated with SNAP 37889 at a dose of 30 mg/kg (i.p.) did not show altered locomotor activity or changes in anxiety-like behaviour in the elevated plus maze or light-dark paradigms. Treatment with SNAP 37889 (30 mg/kg, i.p.) reduced operant responding for solutions containing ethanol, sucrose and saccharin. Collectively, results from the current study showed that SNAP 37889 (30 mg/kg, i.p.) is effective in reducing operant responding for ethanol, independent of a sedative effect.

CONCLUSIONS

These findings provide evidence that GALR3 antagonism reduces alcohol consumption and further suggest that GALR3 may be implicated in the rewarding effects of natural and drug reinforcers.

Imagery Scripts and a Computerized Subtraction Stress Task Both Induce Stress in Methamphetamine Users: A Controlled Laboratory Study

Patients treated for methamphetamine (MA) dependence have a high rate of relapse, and stress is thought to play a key role. We sought to develop a computerized procedure for experimentally inducing stress in MA users. In a within-subjects design, we compared a computerized subtraction stress task (SST) to personalized stress-imagery scripts and a control condition (neutral imagery) in 9 former MA users, recruited in San Francisco in 2006–2007. We assessed blood hormone levels, anxiety and craving for MA on visual analog scales, and the Positive and Negative Affect Schedule and made linear mixed-effects models to analyze the results. Both the SST and stress scripts were effective in inducing self-report markers of stress in MA users. Because the SST is easily reproducible and requires less time of staff and participants, it may be a useful alternative for measuring stress reactivity in drug users.

Naltrexone maintenance for heroin dependence: uptake, attrition and retention

With naltrexone registered only recently in Australia in 1999, it is important to examine the rate of uptake of naltrexone treatment, early attrition and retention rates during treatment, in order to inform the way naltrexone is used in Australian practice. Of 317 people screened for the study, 97 participants were recruited post-withdrawal from opiates and were inducted to naltrexone after a period of at least 5 days of abstinence. While in treatment, participants received a 50-mg dose of naltrexone daily, with daily dispensing for the first 7 days, and weekly dispensing for the following 11 weeks. For the naltrexone-treated sample as a whole, the rate of uptake of naltrexone treatment was 30%, with 30% retained in treatment for the entire 12-week program. Attrition from treatment was found to be steady throughout the 12 weeks. The authors conclude that further research is required to improve withdrawal and naltrexone induction techniques and to improve medication compliance and treatment retention.

Efficacy of maintenance treatment with naltrexone for opioid dependence: a meta-analytical review

AIMS

To determine the efficacy of naltrexone in reducing illicit opioid use and the potential moderating role of treatment retention.

DESIGN

First, randomized controlled trials (RCTs) comparing the regimens of treatment using the opioid antagonist, naltrexone, with controls were analysed by meta-analysis for treatment effect with regard to a range of outcome criteria. The degree of heterogeneity was also determined. The moderating effect of other interventions during naltrexone maintenance was then estimated, particularly with regard to their effect on treatment retention.

PARTICIPANTS

Fifteen studies involving 1,071 patients were found.

MEASUREMENTS

All available outcomes were analysed in 10 studies of naltrexone versus control (seven placebo) and six studies of randomized psychosocial/psychopharmacological interventions.

FINDINGS

Significant heterogeneity was found in the efficacy of naltrexone. Level of retention in treatment was found to be a moderator, explaining most of the heterogeneity found. Overall, naltrexone was significantly better than control conditions in reducing the number of opioid-positive urines. This effect was only present in the high retention subgroup for differences in retention. Contingency management (CM) increased retention and naltrexone use, resulting in a reduced number of opioid-positive urines.

CONCLUSION

Retention is important to the effect of naltrexone in treating opioid dependence. Contingency management is a promising method of increasing retention.

Oral naltrexone maintenance treatment for opioid dependence

BACKGROUND

Research on the clinical application of oral naltrexone agrees on several things. From a pharmacological perspective, naltrexone works. From an applied perspective, however, this medication is not used since the medication compliance and the retention rates are very poor.

OBJECTIVES

To evaluate the effects of naltrexone maintenance treatment versus placebo or other treatments in preventing relapse in opioid addicts after detoxification.

SEARCH STRATEGY

We searched the Cochrane Drugs and Alcohol Group Register of Trials (January 2005), Cochrane Central Register of Controlled Trials (CENTRAL - The Cochrane Library Issue 1, 2005), MEDLINE (1973-first year of naltrexone use in humans- January 2005), EMBASE (1974- January 2005), PsycINFO (OVID-January 1985 to January 2004). We inspected reference lists of relevant articles and we contacted pharmaceutical producers of naltrexone, authors and other Cochrane review groups.

SELECTION CRITERIA

All randomised and controlled clinical trials which focus on the use of naltrexone maintenance treatment versus placebo, or other treatments to reach sustained abstinence from opiate drugs

DATA COLLECTION AND ANALYSIS

Three reviewers independently assessed studies for inclusion and extracted data. One reviewer carried out the qualitative assessments of the methodology of eligible studies using validated checklists.

MAIN RESULTS

Ten studies, 696 participants, met the criteria for inclusion in this review. Only two studies described an adequate allocation concealment. The results show that naltrexone maintenance therapy alone or associated with psychosocial therapy is more efficacious that placebo alone or associated with psychosocial therapy in limiting the use of heroin during the treatment (RR 0,72 95% confidence interval 0.58 to 0.90). If we consider only the studies comparing naltrexone with placebo, the difference do not reach the statistical significancy, RR 0.79 (95%CI 0.59 to 1.06). With respect to the number of participants re incarcerated during the study period, the naltrexone associated with psychosocial therapy is more effective than the psychosocial treatment alone; RR 0.50 (95%CI 0.27 to 0.91). No statistically significant benefit was shown in terms of retention in treatment, side effects or relapse results at follow-up for any of the considered comparisons.

AUTHORS' CONCLUSIONS

Unfortunately the studies did not provide an objective evaluation of naltrexone treatment in the field of opioid dependence. The conclusions are also limited due to the heterogeneity of the trials both in the interventions and in the assessment of outcomes.

A systematic review on the efficacy of naltrexone maintenance treatment in opioid dependence

AIM

To evaluate the efficacy of naltrexone maintenance treatment in preventing relapse in opioid addicts after detoxification.

DESIGN

A systematic review according to the methodology developed by the Cochrane Collaboration based on either randomized controlled trials (RCTs) or controlled clinical trials (CCTs).

PARTICIPANTS

Seven hundred and seven heroin dependent in- and out-patients, or former heroin addicts dependent on methadone and participating in a naltrexone treatment programme; 89% were male.

INTERVENTION

Maintenance treatments on opiate dependent people after detoxification, comparing naltrexone with placebo, pharmacological or behavioural treatments.

MEASUREMENTS

The outcomes considered were successfully completed treatment, opioid use under treatment (re)-incarcerations during the study period, mean duration of treatment.

FINDINGS

The outcomes tended to be slightly although not significantly in favour of the naltrexone groups. Use of naltrexone in addition to behavioural treatment significantly decreased the probability of (re-)incarceration (OR=0.30; 95% CI 0.12, 0.76). The difficulties in producing a quantitative analysis were due mainly to the heterogeneity of the included studies.

CONCLUSIONS

From the available clinical trials performed up to this time, there is insufficient evidence to justify the use of naltrexone in maintenance treatment of opioid addicts.

Naltrexone maintenance treatment for opioid dependence

BACKGROUND

Despite widespread use of naltrexone maintenance in many countries for more than a decade, the evidence of its effects has not yet been systematically evaluated.

OBJECTIVES

To evaluate the effects of naltrexone maintenance treatment in preventing relapse in opioid addicts after detoxification.

SEARCH STRATEGY

We searched MEDLINE (1973-first year of naltrexone use in humans-July 2000), EMBASE (1974-July 2000), Cochrane Controlled Trials Register (Cochrane Library issue 2001.4) and handsearched the "Bolletino per le Farmacodipendenze e l'Alcolismo" (1978 to 1997) and reference lists of relevant articles. We contacted pharmaceutical producers of naltrexone, authors and other Cochrane review groups. Date of most recent searches: December 2001.

SELECTION CRITERIA

All controlled studies of naltrexone; treatment of heroin addicts after detoxification.

DATA COLLECTION AND ANALYSIS

Reviewers evaluated data independently and analysed outcome measures taking into consideration adherence to and success of the study intervention. Data were extracted and analysed stratifying for the three categories of study quality. Where possible, meta-analysis was performed.

MAIN RESULTS

Eleven studies met the criteria for inclusion in this review, even if not all of them were randomised. The methodological quality of the included studies varied, but was generally poor. Meta-analysis could be performed to a very low degree only, because the studies and their outcome measures were very heterogeneous. A statistically significant reduction of (re-)incarcerations was found for patients treated with naltrexone and behaviour therapy in respect to those treated with behaviour therapy only. The other outcomes considered in the meta-analysis did not yield any significant results. Final conclusions on whether naltrexone treatment may be considered effective in maintenance therapy cannot be drawn from the clinical trials available so far.

REVIEWER'S CONCLUSIONS

The available trials do not allow a final evaluation of naltrexone maintenance treatment yet. A trend in favour of treatment with naltrexone was observed for certain target groups (particularly people who are highly motivated), as has been previously described in the literature.

Compliance to naltrexone treatment after ultra-rapid opiate detoxification: an open label naturalistic study

Studies have found that naltrexone, a long-acting opiate antagonist, owing to poor patient compliance, is of limited value in preventing relapse. The current study investigates compliance with a 9-month course of naltrexone (25-50 mg daily) given with counseling after ultra-rapid opiate detoxification which uses clonidine and naltrexone under general anesthesia. Eighty-three of 113 randomly selected patients (out of 640), who were detoxified more than 1 year prior (average 1.5 years), responded to phone interviews. Phone questionnaire asked about patients' compliance with naltrexone, counseling and drug use since detoxification. Similar interviews were also conducted with patients' significant other. Non-relapse patients (n = 47, 57%) took naltrexone an average of 2 months longer than did relapse patients (n = 36, 43%). About half of the non-relapse patients completed at least 5 months of naltrexone, 30% completed at least 7 months and about 20% completed 9 months. Fifty-five percent of the relapse patients stopped using naltrexone by the end of the 3rd month, and by the end of 7th month 10% continued to take it. After the first 2 months the decline in naltrexone compliance was about the same for relapse and non-relapse patients. These results are more encouraging about the use of naltrexone for relapse prevention than previous studies. This method of using naltrexone should be further tested in prospective random assignment controlled studies.

Contingent reinforcement for reduced carbon monoxide levels in methadone maintenance patients

Five cigarette smoking methadone maintenance patients (MMP) participated in a within-subjects (A-B-A-B) study involving repeated application of carbon monoxide (CO)-contingent payments for reductions in smoke intake. To replicate and extend findings from an earlier study in non-drug-abusing smokers (Stitzer & Bigelow, 1982), we used the same contingent reinforcement procedure that involved the delivery of a monetary payment ($5) for CO readings which were 50% or less than the average value of readings obtained during the prior noncontingency period. Although four of the five subjects earned the contingent payment on at least three of the eight occasions, the overall effect of the intervention on CO level was nonsignificant. Daily smoking records revealed significantly lower rates during the first contingency intervention for the group as a whole. Significant correlations between CO and the time interval since smoking prior to CO measurement were found. The rather modest intervention effects suggest that important parameters be considered when designing contingency management procedures to reduce cigarette smoking in this difficult population of drug abusers.

The efficacy of naltrexone in preventing reabuse of heroin after detoxification

The efficacy of Naltrexone in preventing reabuse of heroin among heroin addicts in Israel was studied in a double-blind, controlled design. Naltrexone (or placebo) treatment was given as part of a general treatment plan that continued for 12 weeks. Thirty-two addicts who successfully completed a detoxification program and met research criteria, were included in the study. Fifty milligrams of Naltrexone were taken orally three times a week (25 mg twice a week for the first 2 weeks). The follow-up procedure included an interview, urine tests, and screening for possible adverse effects. In addition, social and psychological parameters were evaluated. Fewer heroin-positive urine tests were found the Naltrexone group than in the placebo group. Throughout the entire study, the number of drug-free patients in the Naltrexone group was higher than in the placebo group. The Naltrexone group showed a significant improvement in most psychological parameters as compared with the placebo group. No differences were found in compliance or ratio of adverse effects between the Naltrexone and placebo groups. The concept "heroin abuse load" based on daily heroin consumption and duration of addiction enabled us to predict which addicts would complete the treatment program. The results suggest that heroin addicts in Israel may benefit from treatment with Naltrexone.

Cigarette smoking and methadone dose levels

Cigarette smoking has been shown to increase consequent to the acute administration of methadone. This suggests the possibility that differences in maintenance dose levels might be associated with differential smoking rates. It is of special concern that higher maintenance levels of methadone may lead to more cigarette smoking because of the putative beneficial effects of higher doses on illicit drug use, treatment retention, and the like. Two experiments were conducted to test the hypothesis that higher maintenance doses of methadone are related to more cigarette smoking. Smoking was measured by self-report and expired carbon monoxide, and the amounts were correlated with subjects' methadone dose levels. The results showed smoking rates of 85% and that self-reported smoking significantly correlated (r = -.52) with CO. Maintenance doses, however, were not correlated with smoking levels. This suggests that the acute effects of methadone on smoking are nullified as clients habituate to dose level, and that decisions regarding appropriate methadone dosage can be made on other grounds.

Treating cigarette smoking in methadone maintenance clients

Substance abusers in treatment have cigarette-smoking rates about three times that found in the general adult population, yet there is a paucity of published studies examining smoking-cessation programs for these clients. Accordingly, a behaviorally based smoking-cessation program for methadone maintenance clients was developed, and the efficacy of a methadone dose increase as a pharmacological adjunct was tested in a double-blind placebo-controlled study. While no significant difference between experimental and control subjects in reported abstinence rates was found, subjects receiving a methadone increase reported significantly more nicotine craving and other withdrawal symptoms during the first week of abstinence than did controls. Measures of smoking rates indicated that experimental subjects smoked significantly more than controls throughout the 10-week study period. Although the initial smoking abstinence rate of 65% was encouraging, most subjects returned to smoking by the end of the study period. These findings indicate that the development of smoking-cessation programs for methadone clients merits further study and that such programs should stress relapse prevention techniques tailored to the specific needs of this population. Also, while the use of a methadone dose increase as a pharmacological adjunct has not been found to be efficacious, other pharmacological strategies involving the use of nicotine should not be ruled out.