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Mannes ZL, Livne O, Knox J, Hasin DS, Kranzler HR. Prevalence and correlates of DSM-5 opioid withdrawal syndrome in U.S. adults with non-medical use of prescription opioids: results from a national sample. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2023; 49:799-808. [PMID: 37948571 PMCID: PMC10867630 DOI: 10.1080/00952990.2023.2248646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 08/13/2023] [Indexed: 11/12/2023]
Abstract
Background: In the U.S. non-medical use of prescription opioids (NMOU) is prevalent and often accompanied by opioid withdrawal syndrome (OWS). OWS has not been studied using nationally representative data.Objectives: We examined the prevalence and clinical correlates of OWS among U.S. adults with NMOU.Methods: We used data from 36,309 U.S. adult participants in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III, 1,527 of whom reported past 12-month NMOU. Adjusted linear and logistic regression models examined associations between OWS and its clinical correlates, including psychiatric disorders, opioid use disorder (OUD; excluding the withdrawal criterion), medical conditions, and healthcare utilization among people with regular (i.e. ≥3 days/week) NMOU (n = 534).Results: Over half (50.4%) of the sample was male. Approximately 9% of people with NMOU met criteria for DSM-5 OWS, with greater prevalence of OWS (∼20%) among people with regular NMOU. Individuals with bipolar disorder, dysthymia, panic disorder, and borderline personality disorder had greater odds of OWS (aOR range = 2.71-4.63). People with OWS had lower mental health-related quality of life (β=-8.32, p < .001). Individuals with OUD also had greater odds of OWS (aOR range = 26.02-27.77), an association that increased with more severe OUD. People using substance use-related healthcare services also had greater odds of OWS (aOR range = 6.93-7.69).Conclusion: OWS was prevalent among people with OUD and some psychiatric disorders. These findings support screening for OWS in people with NMOU and suggest that providing medication- assisted treatments and behavioral interventions could help to reduce the burden of withdrawal in this patient population.
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Affiliation(s)
- Zachary L. Mannes
- Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th St., New York, NY 10032, USA
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA
| | - Ofir Livne
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA
| | - Justin Knox
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA
- Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, New York, NY, 10032, USA
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, 722 West 168th St. New York, NY, 10032, USA
| | - Deborah S. Hasin
- Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th St., New York, NY 10032, USA
- New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY, 10032, USA
- Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, New York, NY, 10032, USA
| | - Henry R. Kranzler
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, Philadelphia, PA, 19104, USA
- Mental Illness Research, Education, and Clinical Center, Crescenz Veterans Affairs Medical Center, 3900 Woodland Ave, Philadelphia, PA, 19104, USA
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2
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Colzato L, Elmers J, Xu X, Zhou Q, Hommel B, Beste C. Regaining control over opioid use? The potential application of auricular transcutaneous vagus nerve stimulation to improve opioid treatment in China. Addict Biol 2023; 28:e13343. [PMID: 37855071 DOI: 10.1111/adb.13343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 05/18/2023] [Accepted: 09/20/2023] [Indexed: 10/20/2023]
Abstract
Opioid use disorder (OUD) is a critical problem in China and is accompanied by depression and deficits in cognitive control. In China, the most successful intervention for OUD is the community drug rehabilitation where methadone maintenance treatment (MMT) plays a key role. Even though methadone for the treatment of OUD can be helpful, it can cause severe somatic side-effects, which limit its effectivity. Even worse, it can have detrimental effects on cognitive control, which is crucial to regain control over drug intake. Here, we consider the potential use of auricular transcutaneous vagus nerve stimulation (atVNS) as an addition to MMT for opioid withdrawal treatment. Compared to other non-invasive brain stimulation methods, atVNS also targets the locus coeruleus (LC) important for noradrenaline (NA) synthesis. NA is an essential neurotransmitter impacted in opioid withdrawal and also critically involved in cognitive control processes. Its ADD-ON to MMT might be a useful mean to improve mood and enhance cognitive control processes impacted in OUD. We discuss the translational advantages of atVNS in China such as the cultural acceptance of the modality of treatment similar to electroacupuncture. Additionally, the wearability of the ear electrode and at-home self-administration without intense medical supervision makes of atVNS a useful tool to enhance clinical and cognitive outcomes especially in everyday life situation. We discuss how atVNS can be integrated in tele-medical health approaches allowing that innovative treatments can widely be disseminated and continued even in situations of restricted medical access.
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Affiliation(s)
- Lorenza Colzato
- Cognitive Psychology, Faculty of Psychology, Shandong Normal University, Jinan, China
| | - Julia Elmers
- Cognitive Neurophysiology, Department of Child and Adolescent Psychiatry, Faculty of Medicine, TU Dresden, Germany
- Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, TU Dresden, Germany
| | - Xiaolei Xu
- Cognitive Psychology, Faculty of Psychology, Shandong Normal University, Jinan, China
| | - Qiang Zhou
- Department of Psychology, Wenzhou Medical University, Wenzhou, China
| | - Bernhard Hommel
- Cognitive Psychology, Faculty of Psychology, Shandong Normal University, Jinan, China
| | - Christian Beste
- Cognitive Psychology, Faculty of Psychology, Shandong Normal University, Jinan, China
- Cognitive Neurophysiology, Department of Child and Adolescent Psychiatry, Faculty of Medicine, TU Dresden, Germany
- Center of Clinical Neuroscience, Department of Neurology, University Hospital Carl Gustav Carus, TU Dresden, Germany
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3
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Jiao S, Bungay V, Jenkins E, Gagnon M. How an emergency department is organized to provide opioid-specific harm reduction and facilitators and barriers to harm reduction implementation: a systems perspective. Harm Reduct J 2023; 20:139. [PMID: 37735432 PMCID: PMC10515241 DOI: 10.1186/s12954-023-00871-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/13/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND The intersection of dual public health emergencies-the COVID-19 pandemic and the drug toxicity crisis-has led to an urgent need for acute care based harm reduction for unregulated opioid use. Emergency Departments (EDs) as Complex Adaptive Systems (CASs) with multiple, interdependent, and interacting elements are suited to deliver such interventions. This paper examines how the ED is organized to provide harm reduction and identifies facilitators and barriers to implementation in light of interactions between system elements. METHODS Using a case study design, we conducted interviews with Emergency Physicians (n = 5), Emergency Nurses (n = 10), and clinical leaders (n = 5). Nine organizational policy documents were also collected. Interview data were analysed using a Reflexive Thematic Analysis approach. Policy documents were analysed using a predetermined coding structure pertaining to staffing roles and responsibilities and the interrelationships therein for the delivery of opioid-specific harm reduction in the ED. The theory of CAS informed data analysis. RESULTS An array of system agents, including substance use specialist providers and non-specialist providers, interacted in ways that enable the provision of harm reduction interventions in the ED, including opioid agonist treatment, supervised consumption, and withdrawal management. However, limited access to specialist providers, when coupled with specialist control, non-specialist reliance, and concerns related to safety, created tensions in the system that hinder harm reduction provision with resulting implications for the delivery of care. CONCLUSIONS To advance harm reduction implementation, there is a need for substance use specialist services that are congruent with the 24 h a day service delivery model of the ED, and for organizational policies that are attentive to discourses of specialized practice, hierarchical relations of power, and the dynamic regulatory landscape. Implementation efforts that take into consideration these perspectives have the potential to reduce harms experienced by people who use unregulated opioids, not only through overdose prevention and improving access to safer opioid alternatives, but also through supporting people to complete their unique care journeys.
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Affiliation(s)
- Sunny Jiao
- School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
| | - Vicky Bungay
- School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada.
| | - Emily Jenkins
- School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
| | - Marilou Gagnon
- School of Nursing, University of Victoria, 3800 Finnerty Road, HSD Building A402a, Victoria, BC, V8P 5C2, Canada
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4
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Hornick MG, Stefanski A. Hallucinogenic potential: a review of psychoplastogens for the treatment of opioid use disorder. Front Pharmacol 2023; 14:1221719. [PMID: 37675046 PMCID: PMC10477608 DOI: 10.3389/fphar.2023.1221719] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 08/09/2023] [Indexed: 09/08/2023] Open
Abstract
The United States is entering its fourth decade of the opioid epidemic with no clear end in sight. At the center of the epidemic is an increase in opioid use disorder (OUD), a complex condition encompassing physical addiction, psychological comorbidities, and socioeconomic and legal travails associated with the misuse and abuse of opioids. Existing behavioral and medication-assisted therapies show limited efficacy as they are hampered by lack of access, strict regimens, and failure to fully address the non-pharmacological aspects of the disease. A growing body of research has indicated the potential of hallucinogens to efficaciously and expeditiously treat addictions, including OUD, by a novel combination of pharmacology, neuroplasticity, and psychological mechanisms. Nonetheless, research into these compounds has been hindered due to legal, social, and safety concerns. This review will examine the preclinical and clinical evidence that psychoplastogens, such as ibogaine, ketamine, and classic psychedelics, may offer a unique, holistic alternative for the treatment of OUD while acknowledging that further research is needed to establish long-term efficacy along with proper safety and ethical guidelines.
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Affiliation(s)
- Mary G. Hornick
- College of Science, Health and Pharmacy, Roosevelt University, Schaumburg, IL, United States
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5
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Giustiniani J, Rothen S, Penzenstadler L, Colombo L, Calzada G, Thorens G, Zullino D. Does slow release oral morphine have impact on craving and impulsivity in heroin dependent individuals? Int Clin Psychopharmacol 2023; 38:16-22. [PMID: 35833289 PMCID: PMC9722371 DOI: 10.1097/yic.0000000000000418] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Craving and impulsivity are addiction components which explain why heroin-dependant individuals (HDI), continue using heroin despite not wanting to do so. Opioid maintenance treatment (OMT), such as slow-release oral morphine (SROM), is the most effective treatment for opioid dependence. However, the impact of SROM on craving and impulsivity remains unclear. In this observational study, 23 HDI receiving SROM, their usual OMT, took part in the experiment. Each of the participants filled in the perceived level of craving with a visual analog scale. Their impulsivity was assessed via three laboratory tasks, the stop-signal reaction time, the Balloon Analogue Risk Task and delay discounting. Each evaluation was performed before and after SROM administration. Craving was significantly reduced after administration of SROM (difference 2.83; P = 0.0010), whereas there were no significant differences in performance in the three laboratory tasks. In the long term, we observed an improvement on delay discounting correlated with the duration and dosage of SROM. The acute impact of SROM appears to significantly reduce craving, without impacting impulsivity. Observation of the correlation between delay discounting and the duration and dosage of OMT is of great interest and should be studied further.
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Affiliation(s)
- Julie Giustiniani
- Addictology Division, Mental Health and Psychiatry Department, Geneva University Hospitals
| | - Stéphane Rothen
- Addictology Division, Mental Health and Psychiatry Department, Geneva University Hospitals
- Research Center for Statistics, University of Geneva, Geneva School of Management and Economics
| | - Louise Penzenstadler
- Addictology Division, Mental Health and Psychiatry Department, Geneva University Hospitals
| | - Laura Colombo
- Addictology Division, Mental Health and Psychiatry Department, Geneva University Hospitals
| | - Gérard Calzada
- Addictology Division, Mental Health and Psychiatry Department, Geneva University Hospitals
- Faculty of Medicine, Geneva University, Geneva, Switzerland
| | - Gabriel Thorens
- Addictology Division, Mental Health and Psychiatry Department, Geneva University Hospitals
- Faculty of Medicine, Geneva University, Geneva, Switzerland
| | - Daniele Zullino
- Addictology Division, Mental Health and Psychiatry Department, Geneva University Hospitals
- Faculty of Medicine, Geneva University, Geneva, Switzerland
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Edinoff AN, Wu NW, Nix CA, Bonin B, Mouhaffel R, Vining S, Gibson W, Cornett EM, Murnane KS, Kaye AM, Kaye AD. Historical Pathways for Opioid Addiction, Withdrawal with Traditional and Alternative Treatment Options with Ketamine, Cannabinoids, and Noribogaine: A Narrative Review. Health Psychol Res 2022; 10:38672. [PMID: 36628122 PMCID: PMC9817468 DOI: 10.52965/001c.38672] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Even as prescription opioid dispensing rates have begun to decrease, the use of illicit opioids such as heroin and fentanyl has increased. Thus, the end of the opioid epidemic is not in sight, and treating patients that are addicted to opioids remains of utmost importance. Currently, the primary pharmacotherapies used to treat opioid addiction over the long term are the opioid antagonist naltrexone, the partial-agonist buprenorphine, and the full agonist methadone. Naloxone is an antagonist used to rapidly reverse opioid overdose. While these treatments are well-established and used regularly, the gravity of the opioid epidemic necessitates that all possible avenues of treatment be explored. Therefore, in this narrative review, we analyze current literature regarding use of the alternative medications ketamine, noribogaine, and cannabinoids in treating patients suffering from opioid use disorder. Beyond its use as an anesthetic, ketamine has been shown to have many applications in several medical specialties. Of particular interest to the subject at hand, ketamine is promising in treating individuals addicted to opioids, alcohol, and cocaine. Therapeutically administered cannabinoids have been proposed for the treatment of multiple illnesses. These include, but are not limited to epilepsy, Parkinson's disease, multiple sclerosis, chronic pain conditions, anxiety disorders, and addiction. The cannabinoid dronabinol has been seen to have varying effects. High doses appear to reduce withdrawal symptoms but this comes at the expense of increased adverse side effects such as sedation and tachycardia. Noribogaine is a weak MOR antagonist and relatively potent KOR agonist, which may explain the clinical anti-addictive effects. More research should be done to assess the viability of these medications for the treatment of OUD and withdrawal.
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Affiliation(s)
- Amber N Edinoff
- Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital; Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Shreveport; Louisiana Addiction Research Center
| | - Natalie W Wu
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Shreveport
| | - Catherine A Nix
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Shreveport; Louisiana Addiction Research Center
| | - Bryce Bonin
- School of Medicine, Louisiana State University Health Shreveport
| | - Rama Mouhaffel
- School of Medicine, Louisiana State University Health Shreveport
| | - Stephen Vining
- School of Medicine, Louisiana State University Health Shreveport
| | - William Gibson
- School of Medicine, Louisiana State University New Orleans
| | - Elyse M Cornett
- Department of Anesthesiology, Louisiana State University Shreveport
| | - Kevin S Murnane
- Department of Psychiatry and Behavioral Medicine, Louisiana State University Health Shreveport; Louisiana Addiction Research Center; Department of Pharmacology, Toxicology & Neuroscience, Louisiana State University Health Shreveport
| | - Adam M Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific
| | - Alan D Kaye
- Louisiana Addiction Research Center, Shreveport; Department of Anesthesiology, Louisiana State University Shreveport
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Wang C, Fan C, Lu Q, Chen W, Liu Y, Xu C, Tang X, Zhou W, Ling L. Exploration of dose tapering strategies for methadone maintenance treatment based on relapse risks: A subpopulation treatment effect pattern plot (STEPP) analysis. Drug Alcohol Depend 2022; 238:109581. [PMID: 35901533 DOI: 10.1016/j.drugalcdep.2022.109581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 07/11/2022] [Accepted: 07/14/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Half of methadone maintenance treatment (MMT) participants experience a tapering phase, however, the guidelines vary from country to country and lack individualized strategies based on relapse risk. A detailed and individualized tapering strategy is needed in China. This study aims to explore dose tapering strategies for Chinese individuals with different relapse risks. METHODS A retrospective study was conducted from 2006 to 2017 at nine MMT clinics in Guangdong, China, involving 549 participants. The end point was the first relapse within 12 months of the start of tapering. Relapse risks before tapering for each participant were determined from a Cox model. RESULTS Out of 549 participants, 173 (31.5 %) relapsed within 12 months after tapering. Findings indicated that a taper dose of less than 5 mg/week is better than other taper doses. Subpopulation treatment effect pattern plot (STEPP) methodology revealed different tapering strategies benefit participants according to relapse risk before tapering. Overall, findings indicated that a less than 5 mg/week reduction in MMT dose is better than reductions of other amounts. For participants with a low relapse risk before tapering, a reduction of less than 2.5 mg/week in MMT dose is better than a 2.5-5 mg/week reduction. CONCLUSIONS A taper dose of less than 5 mg/week appears to be the best dose tapering strategy for Chinese participants. Furthermore, for participants with a low relapse risk, a more gradual taper dose (less than 2.5 mg/week) works better than 2.5-5 mg/week. This benefit was not seen in participants with a high relapse risk before tapering.
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Affiliation(s)
- Chijie Wang
- Department of Medical Statistics, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Chaonan Fan
- Department of Medical Statistics, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Qian Lu
- Hospital of Stomatology, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Wen Chen
- Department of Medical Statistics, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Yin Liu
- Department of Cancer Epidemiology, Henan Office for Cancer Control and Research, Henan Cancer Hospital, Affiliated Cancer Hospital of Zhengzhou University, PR China
| | - Chaofan Xu
- Department of Medical Statistics, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Xijia Tang
- Department of Medical Statistics, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Wensu Zhou
- Department of Medical Statistics, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Li Ling
- Department of Medical Statistics, Sun Yat-sen University, Guangzhou, Guangdong, PR China.
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8
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Chawar C, Hillmer A, Lamri A, Kapczinski F, Thabane L, Pare G, Samaan Z. Implications of OPRM1 and CYP2B6 variants on treatment outcomes in methadone-maintained patients in Ontario: Exploring sex differences. PLoS One 2021; 16:e0261201. [PMID: 34910759 PMCID: PMC8673616 DOI: 10.1371/journal.pone.0261201] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 11/28/2021] [Indexed: 11/19/2022] Open
Abstract
Genetic variants in the OPRM1 and CYP2B6 genes, respectively coding for an opioid receptor and methadone metabolizers, have been linked to negative treatment outcomes in patients undergoing methadone maintenance treatment, with little consensus on their effect. This study aims to test the associations between pre-selected SNPs of OPRM1 and CYP2B6 and outcomes of continued opioid use, relapse, and methadone dose. It also aims to observe differences in associations within the sexes. 1,172 participants treated with methadone (nMale = 666, nFemale = 506) were included in this study. SNPs rs73568641 and rs7451325 from OPRM1 and all the tested CYP2B6 SNPs were detected to be in high linkage disequilibrium. Though no associations were found to be significant, noteworthy differences were observed in associations of OPRM1 rs73568641 and CYP2B6 rs3745274 with treatment outcomes between males and females. Further research is needed to determine if sex-specific differences are present.
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Affiliation(s)
- Caroul Chawar
- Neuroscience Graduate Program, McMaster University, Hamilton, ON, Canada
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, Hamilton, ON, Canada
| | - Alannah Hillmer
- Neuroscience Graduate Program, McMaster University, Hamilton, ON, Canada
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, Hamilton, ON, Canada
| | - Amel Lamri
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Flavio Kapczinski
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, Hamilton, ON, Canada
| | - Lehana Thabane
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Health Research Method, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Father Sean O’Sullivan Research Centre, St. Joseph’s Healthcare Hamilton, Hamilton, ON, Canada
| | - Guillaume Pare
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Health Research Method, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Zainab Samaan
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, Hamilton, ON, Canada
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Opioid Use Disorder Comorbidity in Individuals With Schizophrenia-Spectrum Disorders: A Systematic Review and Meta-Analysis. CANADIAN JOURNAL OF ADDICTION 2021. [DOI: 10.1097/cxa.0000000000000128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Shrestha S, Stopka TJ, Hughto JMW, Case P, Palacios WR, Reilly B, Green TC. Prevalence and correlates of non-fatal overdose among people who use drugs: findings from rapid assessments in Massachusetts, 2017-2019. Harm Reduct J 2021; 18:93. [PMID: 34461922 PMCID: PMC8404353 DOI: 10.1186/s12954-021-00538-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 08/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND People who experience non-fatal overdose (NFOD) are at high risk of subsequent overdose. With unprecedented increases in fentanyl in the US drug supply, many Massachusetts (MA) communities have seen a surge in opioid-related overdoses. The objective of this study was to determine factors associated with lifetime and past year NFOD in at-risk MA communities. METHODS We conducted multiple rapid assessments among people who use drugs (PWUD) in eight MA communities using non-probability sampling (purposive, chain referral, respondent-driven) methods. We collected sociodemographic, substance use, overdose history, substance use treatment, and harm reduction services utilization data. We examined the prevalence of NFOD (lifetime and past year) and identified factors associated with NFOD through multivariable logistic regression analyses in a subset of 469 study participants between 2017 and 2019. RESULTS The prevalence of lifetime and last year non-fatal opioid overdose was 62.5% and 36.9%, respectively. Many of the study participants reported heroin (64%) and fentanyl (45%) use during the 30 days preceding the survey. Nonprescription buprenorphine and fentanyl use were independently associated with higher odds of lifetime NFOD, while marijuana use was associated with lower odds of lifetime NFOD (p < 0.05). Injection as the route of administration, benzodiazepine, nonprescription buprenorphine, heroin, and fentanyl use were independently associated with higher odds, while methadone use was associated with lower odds of past year NFOD (p < 0.05). CONCLUSION We documented a high prevalence of past year and lifetime NFOD among PWUD in MA. Our findings provide indicators that can help inform interventions to prevent overdoses among PWUD, including overdose prevention, medication treatment, and naloxone distribution.
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Affiliation(s)
- Shikhar Shrestha
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Thomas J Stopka
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Jaclyn M W Hughto
- Departments of Behavioral and Social Sciences and Epidemiology, Brown University School of Public Health, Center for Health Promotion and Health Equity, Brown University, Providence, RI, USA
| | - Patricia Case
- Bouvé College of Health Sciences, Northeastern University, Boston, MA, USA
| | - Wilson R Palacios
- School of Criminology and Justice Studies, University of Massachusetts, Lowell, MA, USA
| | - Brittni Reilly
- Massachusetts Department of Public Health, Bureau of Substance Addiction Services, Boston, MA, USA
| | - Traci C Green
- Opioid Policy Research Collaborative, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA.
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11
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Lintzeris N, Mills L, Dunlop A, Copeland J, Mcgregor I, Bruno R, Kirby A, Montebello M, Hall M, Jefferies M, Kevin R, Bhardwaj A. Cannabis use in patients 3 months after ceasing nabiximols for the treatment of cannabis dependence: Results from a placebo-controlled randomised trial. Drug Alcohol Depend 2020; 215:108220. [PMID: 32768992 DOI: 10.1016/j.drugalcdep.2020.108220] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 06/29/2020] [Accepted: 07/28/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION AND AIMS Previous studies suggest cannabinoid agonist treatment is effective in reducing cannabis use in dependent treatment seekers, however few studies have reported on post-treatment outcomes. We examine cannabis use outcomes 12 weeks after cessation of treatment from a randomised placebo-controlled trial of nabiximols for the treatment of cannabis dependence. METHOD 128 participants received either nabiximols (n = 61) or placebo (n = 67) for 12 weeks, in combination with psychosocial interventions. Self-reported number of days of cannabis use in the previous 28 days was measured at baseline, 4, 8, and 12 weeks (end of treatment) and again at 24 weeks (3 months after treatment ceased). Urinalysis was used to confirm self-report data at Week 24 interview. RESULTS A factorial mixed-effects model for repeated measures regression revealed that the nabiximols group used cannabis on 6.8 fewer days in the previous 28 days at week 12 (end of treatment) than the placebo group (p = 0.002, CI: 2.1,11.4), and 6.7 fewer days in the previous 28 days at the week-24 follow-up than the placebo group (p = 0.006, CI: 1.4,12.1). A significantly higher proportion of the nabiximols group (14/61; 23 %) than the placebo group (6/67; 9%) reported abstinence from cannabis in the previous 28 days at the week-24 research interview OR=3.0, CI: 1.1, 9.1; p=0.035, NNT=8, CI: 4, 71). DISCUSSIONS AND CONCLUSIONS The benefits of treatment incorporating nabiximols with psychosocial interventions in reducing cannabis use appears to persist for up to 3 months after the cessation of treatment. A stepped care model of treatment is proposed. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ACTRN12616000103460) https://www.anzctr.org.au.
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Affiliation(s)
- Nicholas Lintzeris
- Drug and Alcohol Services, South East Sydney Local Health District, NSW, Australia; Division Addiction Medicine, Faculty Medicine and Health, University of Sydney, NSW, Australia; NSW Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Australia.
| | - Llewellyn Mills
- Drug and Alcohol Services, South East Sydney Local Health District, NSW, Australia; Division Addiction Medicine, Faculty Medicine and Health, University of Sydney, NSW, Australia; NSW Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Australia
| | - Adrian Dunlop
- NSW Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Australia; Drug and Alcohol Services, Hunter New England Local Health District, NSW, Australia; Priority Research Centre for Brain and Mental Health, School of Medicine and Public Health, University of Newcastle, NSW, Australia
| | | | - Iain Mcgregor
- Lambert Initiative Cannabinoid Therapeutics, University of Sydney, NSW, Australia
| | | | - Adrienne Kirby
- National Health and Medical Research Council, Clinical Trials Centre, Faculty Medicine and Public Health, University of Sydney, NSW, Australia
| | - Mark Montebello
- Drug and Alcohol Services, South East Sydney Local Health District, NSW, Australia; Division Addiction Medicine, Faculty Medicine and Health, University of Sydney, NSW, Australia; NSW Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Australia; University of New South Wales, NSW, Australia
| | - Michelle Hall
- NSW Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Australia; Drug and Alcohol Services, Hunter New England Local Health District, NSW, Australia
| | - Meryem Jefferies
- NSW Drug and Alcohol Clinical Research and Improvement Network (DACRIN), Australia; Drug Health, Western Sydney Local Health District, NSW, Australia
| | - Richard Kevin
- Lambert Initiative Cannabinoid Therapeutics, University of Sydney, NSW, Australia
| | - Anjali Bhardwaj
- Drug and Alcohol Services, South East Sydney Local Health District, NSW, Australia; Division Addiction Medicine, Faculty Medicine and Health, University of Sydney, NSW, Australia; National Health and Medical Research Council, Clinical Trials Centre, Faculty Medicine and Public Health, University of Sydney, NSW, Australia
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Chawar C, Hillmer A, Sanger S, D’Elia A, Panesar B, Guan L, Xie DX, Bansal N, Abdullah A, Kapczinski F, Pare G, Thabane L, Samaan Z. GWAS-identified genetic variants associated with medication-assisted treatment outcomes in patients with opioid use disorder: a systematic review and meta-analysis protocol. Syst Rev 2020; 9:200. [PMID: 32873330 PMCID: PMC7466496 DOI: 10.1186/s13643-020-01461-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 08/21/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The burden of opioid use disorder (OUD) has been increasing in North America. Administration of medication-assisted treatments (MATs) for OUD on an individual-dose basis has been shown to affect patient responses to treatment, proving to be, on occasion, dangerous. A genetic basis has been identified for some MAT responses in a candidate gene context, but consensus has not been reached for any genome-wide significant associations. This systematic review aims to identify and assess any genetic variants associated with MAT patient outcomes at genome-wide significance. METHODS The databases searched by the authors will be: MEDLINE, Web of Science, EMBASE, CINAHL and Pre-CINAHL, GWAS Catalog, GWAS Central, and NIH Database of Genotypes and Phenotypes. A title and abstract screening, full-text screening, data extraction, and quality assessment will be completed in duplicate for each study via Covidence. Treatment outcomes of interest include continued opioid use or abstinence during treatment or at follow-up, time to relapse, treatment retention rates, opioid overdose, other substance use, comorbid psychiatric disorders, risk taking behaviors, MAT plasma concentrations, and mortality rates. Analysis methods applied, if appropriate, will include random effects meta-analysis with pooled odds ratios for all outcomes. Subgroup analyses will also be implemented, when possible. DISCUSSION This systematic review can hopefully inform the direction of future research, aiding in the development of a safer and more patient-centered treatment. It will be able to highlight genome-wide significant variants that are replicable and associated with MAT patient outcomes. SYSTEMATIC REVIEW REGISTRATION This systematic review protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO) (registration ID CRD42020169121).
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Affiliation(s)
- Caroul Chawar
- Neuroscience Graduate Program, McMaster University, Hamilton, ON Canada
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
| | - Alannah Hillmer
- Neuroscience Graduate Program, McMaster University, Hamilton, ON Canada
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
| | - Stephanie Sanger
- Health Sciences Library, McMaster University, Hamilton, ON Canada
| | - Alessia D’Elia
- Neuroscience Graduate Program, McMaster University, Hamilton, ON Canada
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
| | - Balpreet Panesar
- Neuroscience Graduate Program, McMaster University, Hamilton, ON Canada
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
| | - Lucy Guan
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
- Health Sciences Program, McMaster University, Hamilton, ON Canada
| | - Dave Xiaofei Xie
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
- Health Sciences Program, McMaster University, Hamilton, ON Canada
| | - Nandini Bansal
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
- Health Sciences Program, McMaster University, Hamilton, ON Canada
| | - Aamna Abdullah
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
- Health Sciences Program, McMaster University, Hamilton, ON Canada
| | - Flavio Kapczinski
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
| | - Guillaume Pare
- Population Health Research Institute, Hamilton, ON Canada
- Department of Health Research Method, Evidence, and Impact, McMaster University, Hamilton, ON Canada
| | - Lehana Thabane
- Population Health Research Institute, Hamilton, ON Canada
- Department of Health Research Method, Evidence, and Impact, McMaster University, Hamilton, ON Canada
- Father Sean O’Sullivan Research Centre, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
| | - Zainab Samaan
- Department of Psychiatry and Behavioural Neurosciences, St. Joseph’s Healthcare Hamilton, Hamilton, ON Canada
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Opioid agonist therapy trajectories among street entrenched youth in the context of a public health crisis. SSM Popul Health 2020; 11:100609. [PMID: 32613075 PMCID: PMC7317668 DOI: 10.1016/j.ssmph.2020.100609] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 05/27/2020] [Accepted: 06/01/2020] [Indexed: 01/19/2023] Open
Abstract
North America is in the midst of an overdose crisis that is having devastating effects among street entrenched youth (<30 years of age). Opioid agonist therapy (OAT) is a cornerstone of the public health response to this crisis; yet, we struggle to connect youth to OAT across numerous settings. This qualitative study examined perspectives on OAT among street entrenched youth and their providers in Vancouver, Canada. Our findings reveal youth's hopes and fears surrounding making a “full” recovery from past substance use. Youth often equated getting off opioids with “getting back to normal” and the ability to pursue “normal” kinds of futures. While many initiated OAT for short periods of time (<one month) to mediate the discomfort of withdrawal during in-patient treatment, adherence to medications like methadone and buprenorphine over the longer term did not fit with many youth's visions of “normal” futures. A number of polysubstance using youth did not access OAT, despite its lifesaving potential. Youth who did access OAT often preferred methadone because of its perceived ability to mediate longstanding physical and mental health issues. Participants who accessed OAT had the most success with adherence when they were invested in this treatment modality and actively involved in decision making around what kind of medication would work best for them, and for how long. In the absence of this collaboration, many youth made the decision to taper off of OAT independently, frequently resulting in relapse and heightened overdose risk. The overdose crisis in North America is having devastating effects on youth. Opioid agonist therapy (OAT) is a cornerstone of the response to the crisis. Many youth do not view OAT as a part of “full” recovery from opioid use. Many youth pursue OAT to mediate physical and mental health issues. Youth desire ongoing collaboration regarding the length and type of OAT.
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Morgan JR, Wang J, Barocas JA, Jaeger JL, Durham NN, Babakhanlou-Chase H, Bharel M, Walley AY, Linas BP. Opioid overdose and inpatient care for substance use disorder care in Massachusetts. J Subst Abuse Treat 2020; 112:42-48. [PMID: 32199545 PMCID: PMC7928069 DOI: 10.1016/j.jsat.2020.01.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Inpatient treatment for substance use disorders is a collection of strategies ranging from short term detoxification to longer term residential treatment. How those with opioid use disorder (OUD) navigate this inpatient treatment system after an encounter for detoxification and subsequent risk of opioid-related overdose is not well understood. METHODS We used a comprehensive Massachusetts database to characterize the movement of people with OUD through inpatient care from 2013 to 2015, identifying admissions to inpatient detoxification, subsequent inpatient care, and opioid overdose while navigating treatment. We measured the person-years accumulated during each transition period to calculate rates of opioid-related overdose, and investigated how overdose differed in select populations. RESULTS Sixty-one percent of inpatient detoxification admissions resulted in a subsequent inpatient detoxification admission without progressing to further inpatient care. Overall, there were 287 fatal and 7337 non-fatal overdoses. Persons exiting treatment after detoxification had the greatest risk of overdose (17.3 per 100 person-years) compared to those who exited after subsequent inpatient care (ranging from 5.9 to 6.6 overdoses per 100 person-years). Non-Hispanic whites were most at risk for opioid related overdose with 16 overdoses per 100 person-years and non-Hispanic blacks had the lowest risk with 5 overdoses per 100 person-years. CONCLUSIONS The majority of inpatient detoxification admissions do not progress to further inpatient care. Recurrent inpatient detoxification admission is common, likely signifying relapse. Rather than functioning as the first step to inpatient care, inpatient detoxification might be more effective as a venue for implementing strategies to expand addiction services or treatment such as medications for opioid use disorder.
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Affiliation(s)
- Jake R Morgan
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA.
| | - Jianing Wang
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Boston, MA, USA
| | - Joshua A Barocas
- Massachusetts General Hospital, Division of Infectious Diseases, Boston, MA, USA; Brigham and Women's Hospital, Division of Infectious Diseases, Boston, MA, USA
| | | | | | | | - Monica Bharel
- Massachusettes Department of Public Health, Boston, MA, USA
| | - Alexander Y Walley
- Massachusettes Department of Public Health, Boston, MA, USA; Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Benjamin P Linas
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Boston, MA, USA; Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
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Kimbrough A, Kononoff J, Simpson S, Kallupi M, Sedighim S, Palomino K, Conlisk D, Momper JD, de Guglielmo G, George O. Oxycodone self-administration and withdrawal behaviors in male and female Wistar rats. Psychopharmacology (Berl) 2020; 237:1545-1555. [PMID: 32114633 PMCID: PMC7269712 DOI: 10.1007/s00213-020-05479-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 02/06/2020] [Indexed: 12/22/2022]
Abstract
RATIONALE Over the last decade, oxycodone has become one of the most widely abused drugs in the USA. Oxycodone use disorder (OUD) is a serious health problem that has prompted a need to develop animal models of OUD that have both face and predictive validity. Oxycodone use in humans is more prevalent in women and leads to pronounced hyperalgesia and irritability during withdrawal. However, unclear is whether current animal models of oxycodone self-administration recapitulate these characteristics in humans. OBJECTIVES We assessed the face validity of a model of extended-access oxycodone self-administration in rats by examining the escalation of oxycodone intake and behavioral symptoms of withdrawal, including irritability-like behavior and mechanical nociception, in male and female Wistar rats. RESULTS Both male and female rats escalated their oxycodone intake over fourteen 12-h self-administration sessions. After escalation, female rats administered more drug than male rats. No differences in plasma oxycodone levels were identified, but males had a significantly higher level of oxycodone in the brain at 30 min. Extended access to oxycodone significantly decreased aggressive-like behavior and increased defensive-like behaviors when tested immediately after a 12-h self-administration session, followed by a rebound increase in aggressive-like behavior 12 h into withdrawal. Tests of mechanical nociception thresholds during withdrawal indicated pronounced hyperalgesia. No sex differences in irritability-like behavior or pain sensitivity were observed. CONCLUSIONS The present study demonstrated the face validity of the extended access model of oxycodone self-administration by identifying sex differences in the escalation of oxycodone intake and pronounced changes in pain and affective states.
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Affiliation(s)
- Adam Kimbrough
- Department of Psychiatry, School of Medicine, University of California San Diego, 9500 Gilman Drive, MC 0714, La Jolla, CA 92093-0737, USA
| | - Jenni Kononoff
- Department of Neuroscience, The Scripps Research Institute, La Jolla, CA 92037, USA
| | - Sierra Simpson
- Department of Psychiatry, School of Medicine, University of California San Diego, 9500 Gilman Drive, MC 0714, La Jolla, CA 92093-0737, USA,Department of Neuroscience, The Scripps Research Institute, La Jolla, CA 92037, USA
| | - Marsida Kallupi
- Department of Psychiatry, School of Medicine, University of California San Diego, 9500 Gilman Drive, MC 0714, La Jolla, CA 92093-0737, USA
| | - Sharona Sedighim
- Department of Psychiatry, School of Medicine, University of California San Diego, 9500 Gilman Drive, MC 0714, La Jolla, CA 92093-0737, USA
| | - Kenia Palomino
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA 92093, USA
| | - Dana Conlisk
- Department of Neuroscience, The Scripps Research Institute, La Jolla, CA 92037, USA
| | - Jeremiah D. Momper
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA 92093, USA
| | - Giordano de Guglielmo
- Department of Psychiatry, School of Medicine, University of California San Diego, 9500 Gilman Drive, MC 0714, La Jolla, CA 92093-0737, USA
| | - Olivier George
- Department of Psychiatry, School of Medicine, University of California San Diego, 9500 Gilman Drive, MC 0714, La Jolla, CA, 92093-0737, USA.
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Affiliation(s)
- Caroline Mitchell
- Academic Unit of Primary Medical Care, Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, UK
| | | | - Kenneth M Dürsteler
- Center for Addictive Disorders, University of Basel Psychiatric Hospital, Basel, Switzerland
- University Hospital of Psychiatry Zurich, Department for Psychiatry, Psychotherapy and Psychosomatics, Centre for Addictive Disorders, Zurich, Switzerland
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Rieb LM, Samaan Z, Furlan AD, Rabheru K, Feldman S, Hung L, Budd G, Coleman D. Canadian Guidelines on Opioid Use Disorder Among Older Adults. Can Geriatr J 2020; 23:123-134. [PMID: 32226571 PMCID: PMC7067148 DOI: 10.5770/cgj.23.420] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND In Canada, rates of hospital admission from opioid overdose are higher for older adults (≥ 65) than younger adults, and opioid use disorder (OUD) is a growing concern. In response, Health Canada commissioned the Canadian Coalition of Seniors' Mental Health to create guidelines for the prevention, screening, assessment, and treatment of OUD in older adults. METHODS A systematic review of English language literature from 2008-2018 regarding OUD in adults was conducted. Previously published guidelines were evaluated using AGREE II, and key guidelines updated using ADAPTE method, by drawing on current literature. Recommendations were created and assessed using the GRADE method. RESULTS Thirty-two recommendations were created. Prevention recommendations: it is key to prioritize non-pharmacological and non-opioid strategies to treat acute and chronic noncancer pain. Assessment recommendations: a comprehensive assessment is important to help discern contributions of other medical conditions. Treatment recommendations: buprenorphine is first line for both withdrawal management and maintenance therapy, while methadone, slow-release oral morphine, or naltrexone can be used as alternatives under certain circumstances; non-pharmacological treatments should be offered as an integrated part of care. CONCLUSION These guidelines provide practical and timely clinical recommendations on the prevention, assessment, and treatment of OUD in older adults within the Canadian context.
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Affiliation(s)
- Launette M Rieb
- Department of Family Practice, University of British Columbia, Vancouver, BC
| | - Zainab Samaan
- Department of Psychiatry, McMaster University, Hamilton, ON
| | | | - Kiran Rabheru
- Department of Psychiatry, University of Ottawa, Ottawa, ON
| | - Sid Feldman
- Department of Family and Community Medicine, University of Toronto, Toronto, ON
| | - Lillian Hung
- Canadian Gerontological Nurses Association, Toronto, ON
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Scheibe A, Shelly S, Gerardy T, von Homeyer Z, Schneider A, Padayachee K, Naidoo SB, Mtshweni K, Matau A, Hausler H, Marks M. Six-month retention and changes in quality of life and substance use from a low-threshold methadone maintenance therapy programme in Durban, South Africa. Addict Sci Clin Pract 2020; 15:13. [PMID: 32085807 PMCID: PMC7035721 DOI: 10.1186/s13722-020-00186-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 02/08/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Emerging data points to a potential heroin use epidemic in South Africa. Despite this, access to methadone maintenance therapy and other evidence-based treatment options remains negligible. We aimed to assess retention, changes in substance use and quality of life after 6 months on methadone maintenance therapy provided through a low-threshold service in Durban, South Africa. METHODS We enrolled a cohort of 54 people with an opioid use disorder into the study. We reviewed and described baseline socio-demographic characteristics. Baseline and 6-month substance use was assessed using the World Health Organization's Alcohol Smoking and Substance Use Involvement Screening Test (ASSIST) and quality of life, using the SF-12. We compared changes at 6 months on methadone to baseline using the Wilcoxon signed rank test and paired-tests for the ASSIST and SF-12 scores, respectively. McNemar's test was used for comparisons between paired results of categorical variables relating to injecting frequency. RESULTS The majority of the participants were young, Black African males, with a history of drug use spanning over 10 years. Retention after 6 months was 81%. After 6 months, the median heroin ASSIST score decreased from 37 to 9 (p < 0.0001) and the cannabis ASSIST score increased from 12.5 to 21 (p = 0.0003). The median mental health composite score of the SF-12 increased from 41.4 to 48.7 (p = 0.0254). CONCLUSIONS Interim findings suggest high retention, significant reductions in heroin use and improvements in mental health among participants retained on methadone maintenance therapy for 6 months. Further research into longer term outcomes and the reasons contributing to these changes would strengthen recommendations for the scale-up of methadone maintenance therapy in South Africa.
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Affiliation(s)
- Andrew Scheibe
- TB HIV Care, 7th Floor, 11 Adderley Street, Cape Town, South Africa
- Urban Futures Centre, Steve Biko Campus, Durban University of Technology, Durban, South Africa
| | - Shaun Shelly
- TB HIV Care, 7th Floor, 11 Adderley Street, Cape Town, South Africa
- Department of Family Medicine, University of Pretoria, Pretoria, South Africa
| | - Tara Gerardy
- TB HIV Care, 7th Floor, 11 Adderley Street, Cape Town, South Africa
| | - Zara von Homeyer
- TB HIV Care, 7th Floor, 11 Adderley Street, Cape Town, South Africa
| | - Andrea Schneider
- TB HIV Care, 7th Floor, 11 Adderley Street, Cape Town, South Africa
| | | | | | - Klaas Mtshweni
- TB HIV Care, 7th Floor, 11 Adderley Street, Cape Town, South Africa
| | - Ayanda Matau
- TB HIV Care, 7th Floor, 11 Adderley Street, Cape Town, South Africa
| | - Harry Hausler
- TB HIV Care, 7th Floor, 11 Adderley Street, Cape Town, South Africa
| | - Monique Marks
- Urban Futures Centre, Steve Biko Campus, Durban University of Technology, Durban, South Africa
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Carney T, Van Hout MC, Norman I, Dada S, Siegfried N, Parry CDH. Dihydrocodeine for detoxification and maintenance treatment in individuals with opiate use disorders. Cochrane Database Syst Rev 2020; 2:CD012254. [PMID: 32068247 PMCID: PMC7027221 DOI: 10.1002/14651858.cd012254.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Medical treatment and detoxification from opiate disorders includes oral administration of opioid agonists. Dihydrocodeine (DHC) substitution treatment is typically low threshold and therefore has the capacity to reach wider groups of opiate users. Decisions to prescribe DHC to patients with less severe opiate disorders centre on its perceived safety, reduced toxicity, shorter half-life and more rapid onset of action, and potential retention of patients. This review set out to investigate the effects of DHC in comparison to other pharmaceutical opioids and placebos in the detoxification and substitution of individuals with opiate use disorders. OBJECTIVES To investigate the effectiveness of DHC in reducing illicit opiate use and other health-related outcomes among adults compared to other drugs or placebos used for detoxification or substitution therapy. SEARCH METHODS In February 2019 we searched Cochrane Drugs and Alcohol's Specialised Register, CENTRAL, PubMed, Embase and Web of Science. We also searched for ongoing and unpublished studies via ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and Trialsjournal.com. All searches included non-English language literature. We handsearched references of topic-related systematic reviews and the included studies. SELECTION CRITERIA We included randomised controlled trials that evaluated the effect of DHC for detoxification and maintenance substitution therapy for adolescent (aged 15 years and older) and adult illicit opiate users. The primary outcomes were abstinence from illicit opiate use following detoxification or maintenance therapy measured by self-report or urinalysis. The secondary outcomes were treatment retention and other health and behaviour outcomes. DATA COLLECTION AND ANALYSIS We followed the standard methodological procedures that are outlined by Cochrane. This includes the GRADE approach to appraise the quality of evidence. MAIN RESULTS We included three trials (in five articles) with 385 opiate-using participants that measured outcomes at different follow-up periods in this review. Two studies with 150 individuals compared DHC with buprenorphine for detoxification, and one study with 235 participants compared DHC to methadone for maintenance substitution therapy. We downgraded the quality of evidence mainly due to risk of bias and imprecision. For the two studies that compared DHC to buprenorphine, we found low-quality evidence of no significant difference between DHC and buprenorphine for detoxification at six-month follow-up (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.25 to 1.39; P = 0.23) in the meta-analysis for the primary outcome of abstinence from illicit opiates. Similarly, low-quality evidence indicated no difference for treatment retention (RR 1.29, 95% CI 0.99 to 1.68; P = 0.06). In the single trial that compared DHC to methadone for maintenance substitution therapy, the evidence was also of low quality, and there may be no difference in effects between DHC and methadone for reported abstinence from illicit opiates (mean difference (MD) -0.01, 95% CI -0.31 to 0.29). For treatment retention at six months' follow-up in this single trial, the RR calculated with an intention-to-treat analysis also indicated that there may be no difference between DHC and methadone (RR 1.04, 95% CI 0.94 to 1.16). The studies that compared DHC to buprenorphine reported no serious adverse events, while the DHC versus methadone study reported one death due to methadone overdose. AUTHORS' CONCLUSIONS We found low-quality evidence that DHC may be no more effective than other commonly used pharmacological interventions in reducing illicit opiate use. It is therefore premature to make any conclusive statements about the effectiveness of DHC, and it is suggested that further high-quality studies are conducted, especially in low- to middle-income countries.
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Affiliation(s)
- Tara Carney
- South African Medical Research CouncilAlcohol, Tobacco and Other Drug Research UnitFrancie Van Zijl DriveTygerbergWestern CapeSouth Africa7505
| | - Marie Claire Van Hout
- Liverpool John Moores UniversityPublic Health Institute2nd Floor Henry Cotton Campus15‐21 Webster StreetLiverpoolUKL32ET
| | - Ian Norman
- King's College LondonFlorence Nightingale Faculty of Nursing and MidwiferyJames Clerk Maxwell Building , Waterloo RoadLondonUKSE1 8WA
| | - Siphokazi Dada
- South African Medical Research CouncilAlcohol, Tobacco and Other Drug Research UnitFrancie Van Zijl Drive, TygerbergCape TownWestern CapeSouth Africa7505
| | - Nandi Siegfried
- South African Medical Research CouncilAlcohol, Tobacco and Other Drug Research UnitFrancie Van Zijl Drive, TygerbergCape TownWestern CapeSouth Africa7505
| | - Charles DH Parry
- South African Medical Research CouncilAlcohol, Tobacco and Other Drug Research UnitFrancie Van Zijl DriveTygerbergWestern CapeSouth Africa7505
- University of StellenboschDepartment of PsychiatryTygerberg 7505South Africa
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Perry AE, Martyn‐St James M, Burns L, Hewitt C, Glanville JM, Aboaja A, Thakkar P, Santosh Kumar KM, Pearson C, Wright K. Interventions for female drug-using offenders. Cochrane Database Syst Rev 2019; 12:CD010910. [PMID: 31834635 PMCID: PMC6910124 DOI: 10.1002/14651858.cd010910.pub3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND This review represents one in a family of three reviews focusing on the effectiveness of interventions in reducing drug use and criminal activity for offenders. OBJECTIVES To assess the effectiveness of interventions for female drug-using offenders in reducing criminal activity, or drug use, or both. SEARCH METHODS We searched 12 electronic bibliographic databases up to February 2019. SELECTION CRITERIA We included randomised controlled trials (RCTs). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 13 trials with 2560 participants. Interventions were delivered in prison (7/13 studies, 53%) and community (6/13 studies, 47%) settings. The rating of bias was affected by the lack of clear reporting by authors, and we rated many items as 'unclear'. In two studies (190 participants) collaborative case management in comparison to treatment as usual did not reduce drug use (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.20 to 2.12; 1 study, 77 participants; low-certainty evidence), reincarceration at nine months (RR 0.71, 95% CI 0.32 to 1.57; 1 study, 77 participants; low-certainty evidence), and number of subsequent arrests at 12 months (RR 1.11, 95% CI 0.83 to 1.49; 1 study, 113 participants; low-certainty evidence). One study (36 participants) comparing buprenorphine to placebo showed no significant reduction in self-reported drug use at end of treatment (RR 0.57, 95% CI 0.27 to 1.20) and three months (RR 0.58, 95% CI 0.25 to 1.35); very low-certainty evidence. No adverse events were reported. One study (38 participants) comparing interpersonal psychotherapy to a psychoeducational intervention did not find reduction in drug use at three months (RR 0.67, 95% CI 0.30 to 1.50; low-certainty evidence). One study (31 participants) comparing acceptance and commitment therapy (ACT) to a waiting list showed no significant reduction in self-reported drug use using the Addiction Severity Index (mean difference (MD) -0.04, 95% CI -0.37 to 0.29) and abstinence from drug use at six months (RR 2.89, 95% CI 0.73 to 11.43); low-certainty evidence. One study (314 participants) comparing cognitive behavioural skills to a therapeutic community programme and aftercare showed no significant reduction in self-reported drug use (RR 0.86, 95% CI 0.58 to 1.27), re-arrest for any type of crime (RR 0.73, 95% CI 0.52 to 1.03); criminal activity (RR 0.80, 95% CI 0.63 to 1.03), or drug-related crime (RR 0.95, 95% CI 0.68 to 1.32). A significant reduction for arrested (not for parole) violations at six months follow-up was significantly in favour of cognitive behavioural skills (RR 0.43, 95% CI 0.25 to 0.77; very low-certainty evidence). A second study with 115 participants comparing cognitive behavioural skills to an alternative substance abuse treatment showed no significant reduction in reincarceration at 12 months (RR 0.70, 95% CI 0.43 to 1.12; low certainty-evidence. One study (44 participants) comparing cognitive behavioural skills and standard therapy versus treatment as usual showed no significant reduction in Addiction Severity Index (ASI) drug score at three months (MD 0.02, 95% CI -0.05 to 0.09) and six months (MD -0.02, 95% CI -0.09 to 0.05), and incarceration at three months (RR 0.46, 95% CI 0.04 to 4.68) and six months (RR 0.51, 95% CI 0.20 to 1.27); very low-certainty evidence. One study (171 participants) comparing a single computerised intervention versus case management showed no significant reduction in the number of days not using drugs at three months (MD -0.89, 95% CI -4.83 to 3.05; low certainty-evidence). One study (116 participants) comparing dialectic behavioural therapy and case management (DBT-CM) versus a health promotion intervention showed no significant reduction at six months follow-up in positive drug testing (RR 0.67, 95% CI 0.43 to 1.03), number of people not using marijuana (RR 1.23, 95% CI 0.95 to 1.59), crack (RR 1.00, 95% CI 0.87 to 1.14), cocaine (RR 1.02, 95% CI 0.93 to 1.12), heroin (RR 1.05, 95% CI 0.98 to 1.13), methamphetamine (RR 1.02, 95% CI 0.87 to 1.20), and self-reported drug use for any drug (RR 1.20, 95% CI 0.92 to 1.56); very low-certainty evidence. One study (211 participants) comparing a therapeutic community programme versus work release showed no significant reduction in marijuana use at six months (RR 1.03, 95% CI 0.19 to 5.65), nor 18 months (RR 1.00, 95% CI 0.07 to 14.45), heroin use at six months (RR 1.59, 95% CI 0.49 to 5.14), nor 18 months (RR 1.92, 95% CI 0.24 to 15.37), crack use at six months (RR 2.07, 95% CI 0.41 to 10.41), nor 18 months (RR 1.64, 95% CI 0.19 to 14.06), cocaine use at six months (RR 1.09, 95% CI 0.79 to 1.50), nor 18 months (RR 0.93, 95% CI 0.64 to 1.35). It also showed no significant reduction in incarceration for drug offences at 18 months (RR 1.45, 95% CI 0.87 to 2.42); with overall very low- to low-certainty evidence. One study (511 participants) comparing intensive discharge planning and case management versus prison only showed no significant reduction in use of marijuana (RR 0.79, 95% CI 0.53 to 1.16), hard drugs (RR 1.12, 95% CI 0.88 to 1.43), crack cocaine (RR 1.08, 95% CI 0.75 to 1.54), nor positive hair testing for marijuana (RR 0.75, 95% CI 0.55 to 1.03); it found a significant reduction in arrests (RR 0.19, 95% CI 0.04 to 0.87), but no significant reduction in drug charges (RR 1.07, 95% CI 0.75 to 1.53) nor incarceration (RR 1.09, 95% CI 0.86 to 1.39); moderate-certainty evidence. One narrative study summary (211 participants) comparing buprenorphine pre- and post-release from prison showed no significant reduction in drug use at 12 months post-release; low certainty-evidence. No adverse effects were reported. AUTHORS' CONCLUSIONS The studies showed a high degree of heterogeneity for types of comparisons, outcome measures and small samples. Descriptions of treatment modalities are required. On one outcome of arrest (no parole violations), we identified a significant reduction when cognitive behavioural therapy (CBT) was compared to a therapeutic community programme. But for all other outcomes, none of the interventions were effective. Larger trials are required to increase the precision of confidence about the certainty of evidence.
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Affiliation(s)
- Amanda E Perry
- University of YorkDepartment of Health SciencesHeslingtonYorkUKYO105DD
| | - Marrissa Martyn‐St James
- University of SheffieldSchool of Health and Related Research (ScHARR)Regent Court, 30 Regent StreetSheffieldSouth YorkshireUKS1 4DA
| | - Lucy Burns
- University of YorkDepartment of Health SciencesHeslingtonYorkUKYO105DD
| | - Catherine Hewitt
- University of YorkDepartment of Health SciencesHeslingtonYorkUKYO105DD
| | - Julie M Glanville
- York Health Economics ConsortiumMarket SquareUniversity of York, HeslingtonYorkUKYO10 5NH
| | - Anne Aboaja
- Tees, Esk and Wear Valleys NHS Foundation TrustMiddlesbroughUKTS4 3AF
| | | | | | - Caroline Pearson
- University of YorkDepartment of Health SciencesHeslingtonYorkUKYO105DD
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Jordan CJ, Cao J, Newman AH, Xi ZX. Progress in agonist therapy for substance use disorders: Lessons learned from methadone and buprenorphine. Neuropharmacology 2019; 158:107609. [PMID: 31009632 PMCID: PMC6745247 DOI: 10.1016/j.neuropharm.2019.04.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/25/2019] [Accepted: 04/12/2019] [Indexed: 12/12/2022]
Abstract
Substance use disorders (SUD) are serious public health problems worldwide. Although significant progress has been made in understanding the neurobiology of drug reward and the transition to addiction, effective pharmacotherapies for SUD remain limited and a majority of drug users relapse even after a period of treatment. The United States Food and Drug Administration (FDA) has approved several medications for opioid, nicotine, and alcohol use disorders, whereas none are approved for the treatment of cocaine or other psychostimulant use disorders. The medications approved by the FDA for the treatment of SUD can be divided into two major classes - agonist replacement therapies, such as methadone and buprenorphine for opioid use disorders (OUD), nicotine replacement therapy (NRT) and varenicline for nicotine use disorders (NUD), and antagonist therapies, such as naloxone for opioid overdose and naltrexone for promoting abstinence. In the present review, we primarily focus on the pharmacological rationale of agonist replacement strategies in treatment of opioid dependence, and the potential translation of this rationale to new therapies for cocaine use disorders. We begin by describing the neural mechanisms underlying opioid reward, followed by preclinical and clinical findings supporting the utility of agonist therapies in the treatment of OUD. We then discuss recent progress of agonist therapies for cocaine use disorders based on lessons learned from methadone and buprenorphine. We contend that future studies should identify agonist pharmacotherapies that can facilitate abstinence in patients who are motivated to quit their illicit drug use. Focusing on those that are able to achieve abstinence from cocaine will provide a platform to broaden the effectiveness of medication and psychosocial treatment strategies for this underserved population. This article is part of the Special Issue entitled 'New Vistas in Opioid Pharmacology'.
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Affiliation(s)
- Chloe J Jordan
- Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, 21224, USA
| | - Jianjing Cao
- Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, 21224, USA
| | - Amy Hauck Newman
- Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, 21224, USA
| | - Zheng-Xiong Xi
- Molecular Targets and Medications Discovery Branch, National Institute on Drug Abuse, Intramural Research Program, Baltimore, MD, 21224, USA.
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22
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Marks C, Borquez A, Jain S, Sun X, Strathdee SA, Garfein RS, Milloy MJ, DeBeck K, Cepeda JA, Werb D, Martin NK. Opioid agonist treatment scale-up and the initiation of injection drug use: A dynamic modeling analysis. PLoS Med 2019; 16:e1002973. [PMID: 31770373 PMCID: PMC6879119 DOI: 10.1371/journal.pmed.1002973] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 10/18/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Injection drug use (IDU) is associated with multiple health harms. The vast majority of IDU initiation events (in which injection-naïve persons first adopt IDU) are assisted by a person who injects drugs (PWID), and as such, IDU could be considered as a dynamic behavioral transmission process. Data suggest that opioid agonist treatment (OAT) enrollment is associated with a reduced likelihood of assisting with IDU initiation. We assessed the association between recent OAT enrollment and assisting IDU initiation across several North American settings and used dynamic modeling to project the potential population-level impact of OAT scale-up within the PWID population on IDU initiation. METHODS AND FINDINGS We employed data from a prospective multicohort study of PWID in 3 settings (Vancouver, Canada [n = 1,737]; San Diego, United States [n = 346]; and Tijuana, Mexico [n = 532]) from 2014 to 2017. Site-specific modified Poisson regression models were constructed to assess the association between recent (past 6 month) OAT enrollment and history of ever having assisted an IDU initiation with recently assisting IDU initiation. Findings were then pooled using linear mixed-effects techniques. A dynamic transmission model of IDU among the general population was developed, stratified by known factors associated with assisting IDU initiation and relevant drug use behaviors. The model was parameterized to a generic North American setting (approximately 1% PWID) and used to estimate the impact of increasing OAT coverage among PWID from baseline (approximately 21%) to 40%, 50%, and 60% on annual IDU initiation incidence and corresponding PWID population size across a decade. From Vancouver, San Diego, and Tijuana, respectively, 4.5%, 5.2%, and 4.3% of participants reported recently assisting an IDU initiation, and 49.4%, 19.7%, and 2.1% reported recent enrollment in OAT. Recent OAT enrollment was significantly associated with a 45% lower likelihood of providing recent IDU initiation assistance among PWID (relative risk [RR] 0.55 [95% CI 0.36-0.84], p = 0.006) compared to those not recently on OAT. Our dynamic model predicts a baseline mean of 1,067 (2.5%-97.5% interval [95% I 490-2,082]) annual IDU initiations per 1,000,000 individuals, of which 886 (95% I 406-1,750) are assisted by PWID. Based on our observed statistical associations, our dynamic model predicts that increasing OAT coverage from approximately 21% to 40%, 50%, or 60% among PWID could reduce annual IDU initiations by 11.5% (95% I 2.4-21.7), 17.3% (95% I 5.6-29.4), and 22.8% (95% I 8.1-36.8) and reduce the PWID population size by 5.4% (95% I 0.1-12.0), 8.2% (95% I 2.2-16.9), and 10.9% (95% I 3.2-21.8) relative to baseline, respectively, in a decade. Less impact occurs when the protective effect of OAT is diminished, when a greater proportion of IDU initiations are unassisted by PWID, and when average IDU career length is longer. The study's main limitations are uncertainty in the causal pathway between OAT enrollment and assisting with IDU initiation and the use of a simplified model of IDU initiation. CONCLUSIONS In addition to its known benefits on preventing HIV, hepatitis C virus (HCV), and overdose among PWID, our modeling suggests that OAT scale-up may also reduce the number of IDU initiations and PWID population size.
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Affiliation(s)
- Charles Marks
- SDSU-UCSD Joint Doctoral Program in Interdisciplinary Research on Substance Use, San Diego, California, United States of America
- The School of Social Work, San Diego State University, San Diego, California, United States of America
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, United States of America
| | - Annick Borquez
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, United States of America
| | - Sonia Jain
- Biostatistics Research Center, Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California, United States of America
| | - Xiaoying Sun
- Biostatistics Research Center, Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California, United States of America
| | - Steffanie A. Strathdee
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, United States of America
| | - Richard S. Garfein
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, United States of America
| | - M-J Milloy
- British Columbia Centre on Substance Use, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Kora DeBeck
- British Columbia Centre on Substance Use, Vancouver, Canada
- School of Public Policy, Simon Fraser University, Vancouver, Canada
| | - Javier A. Cepeda
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, United States of America
| | - Dan Werb
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, United States of America
| | - Natasha K. Martin
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, United States of America
- Population Health Sciences, University of Bristol, Bristol, United Kingdom
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Degenhardt L, Grebely J, Stone J, Hickman M, Vickerman P, Marshall BDL, Bruneau J, Altice FL, Henderson G, Rahimi-Movaghar A, Larney S. Global patterns of opioid use and dependence: harms to populations, interventions, and future action. Lancet 2019; 394:1560-1579. [PMID: 31657732 PMCID: PMC7068135 DOI: 10.1016/s0140-6736(19)32229-9] [Citation(s) in RCA: 399] [Impact Index Per Article: 79.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 08/15/2019] [Accepted: 09/06/2019] [Indexed: 12/15/2022]
Abstract
We summarise the evidence for medicinal uses of opioids, harms related to the extramedical use of, and dependence on, these drugs, and a wide range of interventions used to address these harms. The Global Burden of Diseases, Injuries, and Risk Factors Study estimated that in 2017, 40·5 million people were dependent on opioids (95% uncertainty interval 34·3-47·9 million) and 109 500 people (105 800-113 600) died from opioid overdose. Opioid agonist treatment (OAT) can be highly effective in reducing illicit opioid use and improving multiple health and social outcomes-eg, by reducing overall mortality and key causes of death, including overdose, suicide, HIV, hepatitis C virus, and other injuries. Mathematical modelling suggests that scaling up the use of OAT and retaining people in treatment, including in prison, could avert a median of 7·7% of deaths in Kentucky, 10·7% in Kiev, and 25·9% in Tehran over 20 years (compared with no OAT), with the greater effects in Tehran and Kiev being due to reductions in HIV mortality, given the higher prevalence of HIV among people who inject drugs in those settings. Other interventions have varied evidence for effectiveness and patient acceptability, and typically affect a narrower set of outcomes than OAT does. Other effective interventions focus on preventing harm related to opioids. Despite strong evidence for the effectiveness of a range of interventions to improve the health and wellbeing of people who are dependent on opioids, coverage is low, even in high-income countries. Treatment quality might be less than desirable, and considerable harm might be caused to individuals, society, and the economy by the criminalisation of extramedical opioid use and dependence. Alternative policy frameworks are recommended that adopt an approach based on human rights and public health, do not make drug use a criminal behaviour, and seek to reduce drug-related harm at the population level.
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Affiliation(s)
- Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney, NSW, Australia.
| | - Jason Grebely
- Kirby Institute, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Jack Stone
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Matthew Hickman
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Peter Vickerman
- Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Julie Bruneau
- Research Center, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada; Department of Family and Emergency Medicine, Faculty of Medicine, Université de Montréal, Succursale Centre-Ville, Montreal, QC, Canada
| | | | | | - Afarin Rahimi-Movaghar
- Iranian National Center for Addiction Studies, Tehran University of Medical Sciences, Tehran, Iran
| | - Sarah Larney
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney, NSW, Australia
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24
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Bruneau J, Ahamad K, Goyer MÈ, Poulin G, Selby P, Fischer B, Wild TC, Wood E. Management of opioid use disorders: a national clinical practice guideline. CMAJ 2019; 190:E247-E257. [PMID: 29507156 DOI: 10.1503/cmaj.170958] [Citation(s) in RCA: 265] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Julie Bruneau
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Keith Ahamad
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Marie-Ève Goyer
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Ginette Poulin
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Peter Selby
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Benedikt Fischer
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - T Cameron Wild
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Evan Wood
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
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25
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Qu L, Ge S, Li N, Wang W, Yang K, Wu P, Wang X, Shi J. Clinical evaluation of deep brain stimulation of nucleus accumbens/anterior limb of internal capsule for opioid relapse prevention: protocol of a multicentre, prospective and double-blinded study. BMJ Open 2019; 9:e023516. [PMID: 30765398 PMCID: PMC6398661 DOI: 10.1136/bmjopen-2018-023516] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Deep brain stimulation (DBS) is a new potential surgical treatment for opioid dependence. However, the implement of DBS treatment in addicted patients is currently controversial due to the significant associated risks. The aim of this study was mainly to investigate the therapeutic efficacy and safety of bilateral DBS of nucleus accumbens and the anterior limb of the internal capsule (NAc/ALIC-DBS) in patients with refractory opioid dependence (ROD). METHODS AND ANALYSIS 60 patients with ROD will be enrolled in this multicentre, prospective, double-blinded study, and will be followed up for 25 weeks (6 months) after surgery. Patients with ROD (semisynthetic opioids) who meet the criteria for NAc/ALIC-DBS surgery will be allocated to either the early stimulation group or the late stimulation group (control group) based on the randomised ID number. The primary outcome was defined as the abstinence rate at 25 weeks after DBS stimulation on, which will be confirmed by an opiate urine tests. The secondary outcomes include changes in the Visual Analogue Scale (VAS) score for craving for opioid drugs, body weight, as well as psychological evaluation measured using the 17-item Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, the Pittsburgh Sleep Quality Index, Fagerstrom test for nicotine dependence assessment, social disability screening schedule, the Activity of Daily Living Scale, the 36-item Short Form-Health Survey and safety profiles of both groups. ETHICS AND DISSEMINATION The study received ethical approval from the medical ethical committee of Tangdu Hospital, The Fourth Military Medical University, Xi'an, China. The results of this study will be published in a peer-reviewed journal and presented at international conferences. TRIAL REGISTRATION NUMBER NCT03424616; Pre-results.
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Affiliation(s)
- Liang Qu
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi’an, China
| | - Shunnan Ge
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi’an, China
| | - Nan Li
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi’an, China
| | - Wei Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Kaijun Yang
- Department of Neurosurgery, Southern Hospital, Southern Medical University, Guangzhou, China
| | - Ping Wu
- National Institute on Drug Dependence, Peking University, Beijing, China
| | - Xuelian Wang
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi’an, China
| | - Jie Shi
- National Institute on Drug Dependence, Peking University, Beijing, China
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Blanco-Gandía MC, Rodríguez-Arias M. Pharmacological treatments for opiate and alcohol addiction: A historical perspective of the last 50 years. Eur J Pharmacol 2018; 836:89-101. [DOI: 10.1016/j.ejphar.2018.08.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 07/13/2018] [Accepted: 08/03/2018] [Indexed: 12/17/2022]
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Vipler S, Hayashi K, Milloy MJ, Wood E, Nosova E, Kerr T, Ti L. Use of withdrawal management services among people who use illicit drugs in Vancouver, Canada. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2018; 13:27. [PMID: 29976225 PMCID: PMC6034285 DOI: 10.1186/s13011-018-0164-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 06/26/2018] [Indexed: 12/21/2022]
Abstract
Background For many individuals with substance use disorders, the entry point for addiction treatment can be through withdrawal management (e.g. detoxification) services. However, little is known about the factors that predict withdrawal management service use among people who use illicit drugs (PWUD). Using data derived from two prospective cohorts of PWUD, we conducted a longitudinal data analysis of factors associated with use of withdrawal management services. Methods Individuals participating in two cohorts of PWUD were prospectively followed between December 2005 and May 2016 in Vancouver, Canada. Bivariate and multivariate generalized estimating equations were used to examine factors associated with use of withdrawal management services. Results Out of a total of 2001 participants, 339 (16.9%) individuals reported having been to a withdrawal management centre in the previous 6 months at some point during the study period. In multivariate analyses, male sex (adjusted odds ratio [AOR]: 1.62, 95% Confidence Interval [CI]: 1.17–2.24), homelessness (AOR: 1.86, 95% CI: 1.45–2.38), binge use of any substance (AOR: 1.34, 95% CI: 1.08–1.67), having attended a supervised injection facility (AOR: 1.66, 95% CI: 1.3–2.11), and having accessed other addiction medicine treatment or supports (other than withdrawal management services or opioid agonist therapy; AOR: 3.34, 95% CI: 2.64–4.22) were positively associated with having accessed withdrawal management services, whereas older age (AOR: 0.81, 95% CI: 0.7–0.94) was negatively associated with the outcome. Conclusions This study identified specific factors associated with accessing withdrawal management services. Current evidence suggests a need to re-examine the provision of withdrawal management services. Consideration needs to be given to redesigning access to care and bridging to evidence-based addiction treatment, particularly for highly vulnerable subpopulations, identified in this study as females and older people.
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Affiliation(s)
- Sharon Vipler
- BC Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.,Department of Family Practice, University of British Columbia, 320 - 5950 University Boulevard, Vancouver, BC, V6T 1Z6, Canada
| | - Kanna Hayashi
- BC Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.,Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada
| | - M-J Milloy
- BC Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Evan Wood
- BC Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Ekaterina Nosova
- BC Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
| | - Thomas Kerr
- BC Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Lianping Ti
- British Columbia Centre for Excellence in HIV/AIDS, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. .,Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
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Weinstein ZM, Wakeman SE, Nolan S. Inpatient Addiction Consult Service: Expertise for Hospitalized Patients with Complex Addiction Problems. Med Clin North Am 2018; 102:587-601. [PMID: 29933817 PMCID: PMC6750950 DOI: 10.1016/j.mcna.2018.03.001] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Substance use disorders are highly prevalent and are a large driver of costly inpatient medical care; however, historically the substance use disorder has gone unaddressed during an inpatient stay. Inpatient addiction consult services are an important intervention to use the reachable moment of hospitalization to engage patients and initiate addiction treatment. Addiction consultation involves taking an addiction-specific history, motivational interviewing, withdrawal symptom management, and initiation of long-term pharmacotherapy. Addiction consult services have the potential to decrease readmissions and utilization costs for medical systems and improve substance-related outcomes for patients.
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Affiliation(s)
- Zoe M Weinstein
- Department of Medicine, Boston University School of Medicine, Boston Medical Center, 801 Massachusetts Avenue, Crosstown 2, Boston, MA 02118, USA.
| | - Sarah E Wakeman
- Department of Medicine, Harvard Medical School, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA 02114, USA
| | - Seonaid Nolan
- British Columbia Centre on Substance Use, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 553B-1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada
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Rahimi‐Movaghar A, Gholami J, Amato L, Hoseinie L, Yousefi‐Nooraie R, Amin‐Esmaeili M. Pharmacological therapies for management of opium withdrawal. Cochrane Database Syst Rev 2018; 6:CD007522. [PMID: 29929212 PMCID: PMC6513031 DOI: 10.1002/14651858.cd007522.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Pharmacologic therapies for management of heroin withdrawal have been studied and reviewed widely. Opium dependence is generally associated with less severe dependence and milder withdrawal symptoms than heroin. The evidence on withdrawal management of heroin might therefore not be exactly applicable for opium. OBJECTIVES To assess the effectiveness and safety of various pharmacologic therapies for the management of the acute phase of opium withdrawal. SEARCH METHODS We searched the following sources up to September 2017: CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, regional and national databases (IMEMR, Iranmedex, and IranPsych), main electronic sources of ongoing trials, and reference lists of all relevant papers. In addition, we contacted known investigators to obtain missing data or incomplete trials. SELECTION CRITERIA Controlled clinical trials and randomised controlled trials on pharmacological therapies, compared with no intervention, placebo, other pharmacologic treatments, different doses of the same drug, and psychosocial intervention, to manage acute withdrawal from opium in a maximum duration of 30 days. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. MAIN RESULTS We included 13 trials involving 1096 participants. No pooled analysis was possible. Studies were carried out in three countries, Iran, India, and Thailand, in outpatient and inpatient settings. The quality of the evidence was generally very low.When the mean of withdrawal symptoms was provided for several days, we mainly focused on day 3. The reason for this was that the highest severity of opium withdrawal is in the second to fourth day.Comparing different pharmacological treatments with each other, clonidine was twice as good as methadone for completion of treatment (risk ratio (RR) 2.01, 95% confidence interval (CI) 1.69 to 2.38; 361 participants, 1 study, low-quality evidence). All the other results showed no differences between the considered drugs: baclofen versus clonidine (RR 1.06, 95% CI 0.63 to 1.80; 66 participants, 1 study, very low-quality evidence); clonidine versus clonidine plus amantadine (RR 1.03, 95% CI 0.86 to 1.24; 69 participants, 1 study); clonidine versus buprenorphine in an inpatient setting (RR 1.04, 95% CI 0.90 to 1.20; 1 study, 35 participants, very low-quality evidence); methadone versus tramadol (RR 0.95, 95% CI 0.65 to 1.37; 1 study, 72 participants, very low-quality evidence); methadone versus methadone plus gabapentin (RR 1.17, 95% CI 0.96 to 1.43; 1 study, 40 participants, low-quality evidence), and tincture of opium versus methadone (1 study, 74 participants, low-quality evidence).Comparing different pharmacological treatments with each other, adding amantadine to clonidine decreased withdrawal scores rated at day 3 (mean difference (MD) -3.56, 95% CI -5.97 to -1.15; 1 study, 60 participants, very low-quality evidence). Comparing clonidine with buprenorphine in an inpatient setting, we found no difference in withdrawal symptoms rated by a physician (MD -1.40, 95% CI -2.93 to 0.13; 1 study, 34 participants, very low-quality evidence), and results in favour of buprenorpine when rated by participants (MD -11.80, 95% CI -15.56 to -8.04). Buprenorphine was superior to clonidine in controlling severe withdrawal symptoms in an outpatient setting (RR 0.35, 95% CI 0.19 to 0.64; 1 study, 76 participants). We found no difference in the comparison of methadone versus tramadol (MD 0.04, 95% CI -2.68 to 2.76; 1 study, 72 participants) and in the comparison of methadone versus methadone plus gabapentin (MD -2.20, 95% CI -6.72 to 2.32; 1 study, 40 participants).Comparing clonidine versus buprenorphine in an outpatient setting, more adverse effects were reported in the clonidine group (1 study, 76 participants). Higher numbers of participants in the clonidine group experienced hypotension at days 5 to 8, headache at days 1 to 8, sedation at days 5 to 8, dizziness and dry mouth at days 1 to 10, and nausea at days 1 to 9. Sweating was reported in a significantly higher number of participants in the buprenorphine group at days 1 to 10. We found no difference between groups for all the other comparisons considering this outcome.Comparing different dosages of the same pharmacological detoxification treatment, a high dose of clonidine (1 to 1.2 mg/day) did not differ from a low dose of clonidine (0.5 to 0.6 mg/day) in completion of treatment in an inpatient setting (RR 1.00, 95% CI 0.84 to 1.19; 1 study, 68 participants), however a higher number of participants with hypotension was reported in the high-dose group (RR 3.25, 95% CI 1.77 to 5.98). Gradual reduction of methadone was associated with more adverse effects than abrupt withdrawal of methadone (RR 2.25, 95% CI 1.02 to 4.94; 1 study, 20 participants, very low-quality evidence). AUTHORS' CONCLUSIONS Results did not support using any specific pharmacological approach for the management of opium withdrawal due to generally very low-quality evidence and small or no differences between treatments. However, it seems that opium withdrawal symptoms are significant, especially at days 2 to 4 after discontinuation of opium. All of the assessed medications might be useful in alleviating symptoms. Those who receive clonidine might experience hypotension.
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Affiliation(s)
- Afarin Rahimi‐Movaghar
- Tehran University of Medical SciencesIranian National Center for Addiction Studies (INCAS)No. 486, South Karegar Ave.TehranTehranIran1336616357
| | - Jaleh Gholami
- Tehran University of Medical SciencesIranian National Center for Addiction Studies (INCAS)No. 486, South Karegar Ave.TehranTehranIran1336616357
| | - Laura Amato
- Lazio Regional Health ServiceDepartment of EpidemiologyVia Cristoforo Colombo, 112RomeItaly00154
| | - Leila Hoseinie
- Tehran University of Medical SciencesIranian National Center for Addiction Studies (INCAS)No. 486, South Karegar Ave.TehranTehranIran1336616357
| | - Reza Yousefi‐Nooraie
- University of TorontoInstitute of Health Policy, Management and Evaluation155 College StreetTorontoONCanadaM5T 3M6
| | - Masoumeh Amin‐Esmaeili
- Tehran University of Medical SciencesIranian National Center for Addiction Studies (INCAS)No. 486, South Karegar Ave.TehranTehranIran1336616357
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Abstract
Foil Smoking/Heroin Inhalation Abstract. Foil smoking is generally heroin consumption by inhalation. By heating an aluminum foil with a fire lighter the heroin on top of the foil starts melting and the smoke is then inhaled using a straw. Foil smoking is the second most common form of heroin consumption after the intravenous use. In contrast to the IV administration, heroin inhalation effects are delayed by a few minutes and the risk of transmission of HIV, Hepatitis or other infectious diseases is not relevant. Severe bronchospasms can occur in patients with or without prior pulmonary disease such as asthma bronchiale. One cerebral consequence of foil smoking is leukoencephalopathy, a spongiform degeneration of the white matter. This is likely triggered by the pyrolysate generated during the heating process. Multiple drug use and concomitant cigarette smoking in heroin addicts make cause-effect relationships difficult to assess. In general, the history of inhalative heroin consumption should be considered in patients presenting with any unkown pulmonary disease with severe bronchospasms as may happen in a severe asthma exacerbation.
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Affiliation(s)
- Ayla Yalamanoglu
- 1 Klinik für Pneumologie und Klinik und Poliklinik für Innere Medizin, Universitätsspital Zürich
| | - Macé M Schuurmans
- 1 Klinik für Pneumologie und Klinik und Poliklinik für Innere Medizin, Universitätsspital Zürich
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31
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Pierce M, Bird SM, Hickman M, Marsden J, Dunn G, Seddon T, Millar T. Effect of initiating drug treatment on the risk of drug-related poisoning death and acquisitive crime among offending heroin users. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 51:42-51. [PMID: 29156402 PMCID: PMC5788328 DOI: 10.1016/j.drugpo.2017.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/17/2017] [Accepted: 09/26/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND A recent Cochrane review of randomised trials identified a lack of evidence for interventions provided to drug-using offenders. We use routine data to address whether contact with treatment services reduces heroin users' likelihood of a future acquisitive offence or drug-related poisoning (DRP) death. METHODS Heroin-users were identified from probation assessments and linked to drug-treatment, mortality and offending records. The study cohort was selected to ensure that the subject was not: in prison, in treatment or had recently left treatment. Subjects were classed as initiators if they attended a triage appointment within two weeks of their assessment; non-initiators otherwise. Initiator and non-initiators were compared over a maximum of one year, with respect to their risk of recorded acquisitive offence or DRP-death. Balance was sought using propensity score matching and missing data were accounted for using multiple imputation. RESULTS Nine percent of assessments identified for analysis were classed as initiators. Accounting for observed confounding and missing data, there was a reduction in DRPs associated with initiator assessments, however there was uncertainty around this estimate such that a null-effect could not be ruled out (HR: 0.42, 95% CI 0.17-1.04). There was no evidence of a decrease in the recidivism risk, in fact the analysis showed a small increase (HR: 1.10, 95% CI 1.02-1.18). CONCLUSION For heroin-using offenders, initial contact with treatment services does not appear to reduce the likelihood of a future acquisitive offence.
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Affiliation(s)
- Matthias Pierce
- School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK.
| | - Sheila M Bird
- MRC Biostatistics Unit at University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Matthew Hickman
- School of Social and Community Medicine, University of Bristol, UK
| | - John Marsden
- Addictions Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Graham Dunn
- School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK
| | | | - Tim Millar
- School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK
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Platt L, Minozzi S, Reed J, Vickerman P, Hagan H, French C, Jordan A, Degenhardt L, Hope V, Hutchinson S, Maher L, Palmateer N, Taylor A, Bruneau J, Hickman M. Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs. Cochrane Database Syst Rev 2017; 9:CD012021. [PMID: 28922449 PMCID: PMC5621373 DOI: 10.1002/14651858.cd012021.pub2] [Citation(s) in RCA: 130] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugsNeedle syringe programmes (NSP) and opioid substitution therapy (OST) are the primary interventions to reduce hepatitis C (HCV) transmission in people who inject drugs. There is good evidence for the effectiveness of NSP and OST in reducing injecting risk behaviour and increasing evidence for the effectiveness of OST and NSP in reducing HIV acquisition risk, but the evidence on the effectiveness of NSP and OST for preventing HCV acquisition is weak. OBJECTIVES To assess the effects of needle syringe programmes and opioid substitution therapy, alone or in combination, for preventing acquisition of HCV in people who inject drugs. SEARCH METHODS We searched the Cochrane Drug and Alcohol Register, CENTRAL, the Cochrane Database of Systematic Reviews (CDSR), the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment Database (HTA), the NHS Economic Evaluation Database (NHSEED), MEDLINE, Embase, PsycINFO, Global Health, CINAHL, and the Web of Science up to 16 November 2015. We updated this search in March 2017, but we have not incorporated these results into the review yet. Where observational studies did not report any outcome measure, we asked authors to provide unpublished data. We searched publications of key international agencies and conference abstracts. We reviewed reference lists of all included articles and topic-related systematic reviews for eligible papers. SELECTION CRITERIA We included prospective and retrospective cohort studies, cross-sectional surveys, case-control studies and randomised controlled trials that measured exposure to NSP and/or OST against no intervention or a reduced exposure and reported HCV incidence as an outcome in people who inject drugs. We defined interventions as current OST (within previous 6 months), lifetime use of OST and high NSP coverage (regular attendance at an NSP or all injections covered by a new needle/syringe) or low NSP coverage (irregular attendance at an NSP or less than 100% of injections covered by a new needle/syringe) compared with no intervention or reduced exposure. DATA COLLECTION AND ANALYSIS We followed the standard Cochrane methodological procedures incorporating new methods for classifying risk of bias for observational studies. We described study methods against the following 'Risk of bias' domains: confounding, selection bias, measurement of interventions, departures from intervention, missing data, measurement of outcomes, selection of reported results; and we assigned a judgment (low, moderate, serious, critical, unclear) for each criterion. MAIN RESULTS We identified 28 studies (21 published, 7 unpublished): 13 from North America, 5 from the UK, 4 from continental Europe, 5 from Australia and 1 from China, comprising 1817 incident HCV infections and 8806.95 person-years of follow-up. HCV incidence ranged from 0.09 cases to 42 cases per 100 person-years across the studies. We judged only two studies to be at moderate overall risk of bias, while 17 were at serious risk and 7 were at critical risk; for two unpublished datasets there was insufficient information to assess bias. As none of the intervention effects were generated from RCT evidence, we typically categorised quality as low. We found evidence that current OST reduces the risk of HCV acquisition by 50% (risk ratio (RR) 0.50, 95% confidence interval (CI) 0.40 to 0.63, I2 = 0%, 12 studies across all regions, N = 6361), but the quality of the evidence was low. The intervention effect remained significant in sensitivity analyses that excluded unpublished datasets and papers judged to be at critical risk of bias. We found evidence of differential impact by proportion of female participants in the sample, but not geographical region of study, the main drug used, or history of homelessness or imprisonment among study samples.Overall, we found very low-quality evidence that high NSP coverage did not reduce risk of HCV acquisition (RR 0.79, 95% CI 0.39 to 1.61) with high heterogeneity (I2 = 77%) based on five studies from North America and Europe involving 3530 participants. After stratification by region, high NSP coverage in Europe was associated with a 76% reduction in HCV acquisition risk (RR 0.24, 95% CI 0.09 to 0.62) with less heterogeneity (I2 =0%). We found low-quality evidence of the impact of combined high coverage of NSP and OST, from three studies involving 3241 participants, resulting in a 74% reduction in the risk of HCV acquisition (RR 0.26 95% CI 0.07 to 0.89). AUTHORS' CONCLUSIONS OST is associated with a reduction in the risk of HCV acquisition, which is strengthened in studies that assess the combination of OST and NSP. There was greater heterogeneity between studies and weaker evidence for the impact of NSP on HCV acquisition. High NSP coverage was associated with a reduction in the risk of HCV acquisition in studies in Europe.
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Affiliation(s)
- Lucy Platt
- London School of Hygiene and Tropical MedicineDepartment of Social and Environmental Health Research15 ‐ 17 Tavistock PlaceLondonUKWC1H 9SH
| | - Silvia Minozzi
- Lazio Regional Health ServiceDepartment of EpidemiologyVia Cristoforo Colombo, 112RomeItaly00154
| | | | - Peter Vickerman
- University of BristolSchool of Social and Community MedicineBristolUK
| | - Holly Hagan
- New York University College of NursingNew YorkNYUSA
| | - Clare French
- University of BristolSchool of Social and Community MedicineBristolUK
| | - Ashly Jordan
- New York University College of NursingNew YorkNYUSA
| | - Louisa Degenhardt
- UNSWNational Drug and Alcohol Research CentreBuilding R322‐32 King StreetRandwickNSWAustralia2031
| | - Vivian Hope
- Liverpool John Moores UniversityPublic Health InstituteLiverpoolUKL3 2ET
| | | | - Lisa Maher
- Kirby Institute, University of New South WalesSydneyAustralia
| | | | | | - Julie Bruneau
- University of MontrealDepartment of Family and Emergency MedicineMontrealCanada
| | - Matthew Hickman
- University of BristolSchool of Social and Community MedicineBristolUK
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Platt L, Sweeney S, Ward Z, Guinness L, Hickman M, Hope V, Hutchinson S, Maher L, Iversen J, Craine N, Taylor A, Munro A, Parry J, Smith J, Vickerman P. Assessing the impact and cost-effectiveness of needle and syringe provision and opioid substitution therapy on hepatitis C transmission among people who inject drugs in the UK: an analysis of pooled data sets and economic modelling. PUBLIC HEALTH RESEARCH 2017. [DOI: 10.3310/phr05050] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background
There is limited evidence of the impact of needle and syringe programmes (NSPs) and opioid substitution therapy (OST) on hepatitis C virus (HCV) incidence among people who inject drugs (PWID), nor have there been any economic evaluations.
Objective(s)
To measure (1) the impact of NSP and OST, (2) changes in the extent of provision of both interventions, and (3) costs and cost-effectiveness of NSPs on HCV infection transmission.
Design
We conducted (1) a systematic review; (2) an analysis of existing data sets, including collating costs of NSPs; and (3) a dynamic deterministic model to estimate the impact of differing OST/NSP intervention coverage levels for reducing HCV infection prevalence, incidence and disease burden, and incremental cost-effectiveness ratios to measure the cost-effectiveness of current NSP provision versus no provision.
Setting
Cost-effectiveness analysis and impact modelling in three UK sites. The pooled analysis drew on data from the UK and Australia. The review was international.
Participants
PWID.
Interventions
NSP coverage (proportion of injections covered by clean needles) and OST.
Outcome
New cases of HCV infection.
Results
The review suggested that OST reduced the risk of HCV infection acquisition by 50% [rate ratio (RR) 0.50, 95% confidence interval (CI) 0.40 to 0.63]. Weaker evidence was found in areas of high (≥ 100%) NSP coverage (RR 0.77, 95% CI 0.38 to 1.54) internationally. There was moderate evidence for combined high coverage of NSPs and OST (RR 0.29, 95% CI 0.13 to 0.65). The pooled analysis showed that combined high coverage of NSPs and OST reduced the risk of HCV infection acquisition by 29–71% compared with those on minimal harm reduction (no OST, ≤ 100% NSP coverage). NSPs are likely to be cost-effective and are cost-saving in some settings. The impact modelling suggest that removing OST (current coverage 81%) and NSPs (coverage 54%) in one site would increase HCV infection incidence by 329% [95% credible interval (CrI) 110% to 953%] in 2031 and at least double (132% increase; 95% CrI 51% to 306%) the number of new infections over 15 years. Increasing NSP coverage to 80% has the largest impact in the site with the lowest current NSP coverage (35%), resulting in a 27% (95% CrI 7% to 43%) decrease in new infections and 41% (95% CrI 11% to 72%) decrease in incidence by 2031 compared with 2016. Addressing homelessness and reducing the harm associated with the injection of crack cocaine could avert approximately 60% of HCV infections over the next 15 years.
Limitations
Findings are limited by the misclassification of NSP coverage and the simplified intervention definition that fails to capture the integrated services that address other social and health needs as part of this.
Conclusions
There is moderate evidence of the effectiveness of OST and NSPs, especially in combination, on HCV infection acquisition risk. Policies to ensure that NSPs can be accessed alongside OST are needed. NSPs are cost-saving in some sites and cost-effective in others. NSPs and OST are likely to prevent considerable rates of HCV infection in the UK. Increasing NSP coverage will have most impact in settings with low coverage. Scaling up other interventions such as HCV infection treatment are needed to decrease epidemics to low levels in higher prevalence settings.
Future work
To understand the mechanisms through which NSPs and OST achieve their effect and the optimum contexts to support implementation.
Funding
The National Institute for Health Research Public Health Research programme.
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Affiliation(s)
- Lucy Platt
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Sedona Sweeney
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Zoe Ward
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Lorna Guinness
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Matthew Hickman
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Vivian Hope
- Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK
| | - Sharon Hutchinson
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Lisa Maher
- Viral Hepatitis Epidemiology and Prevention Program, Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Jenny Iversen
- Viral Hepatitis Epidemiology and Prevention Program, Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Noel Craine
- Health Protection Division, Public Health Wales, Cardiff, UK
| | - Avril Taylor
- School of Media Society and Culture, University of the West of Scotland, Paisley, UK
| | - Alison Munro
- School of Social Science, University of the West of Scotland, Paisley, UK
| | - John Parry
- Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK
| | - Josie Smith
- Health Protection Division, Public Health Wales, Cardiff, UK
| | - Peter Vickerman
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Abstract
BACKGROUND Managed withdrawal is a necessary step prior to drug-free treatment or as the endpoint of long-term substitution treatment. OBJECTIVES To assess the effects of opioid antagonists plus minimal sedation for opioid withdrawal. Comparators were placebo as well as more established approaches to detoxification, such as tapered doses of methadone, adrenergic agonists, buprenorphine and symptomatic medications. SEARCH METHODS We updated our searches of the following databases to December 2016: CENTRAL, MEDLINE, Embase, PsycINFO and Web of Science. We also searched two trials registers and checked the reference lists of included studies for further references to relevant studies. SELECTION CRITERIA We included randomised and quasi-randomised controlled clinical trials along with prospective controlled cohort studies comparing opioid antagonists plus minimal sedation versus other approaches or different opioid antagonist regimens for withdrawal in opioid-dependent participants. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS Ten studies (6 randomised controlled trials and 4 prospective cohort studies, involving 955 participants) met the inclusion criteria for the review. We considered 7 of the 10 studies to be at high risk of bias in at least one of the domains we assessed.Nine studies compared an opioid antagonist-adrenergic agonist combination versus a treatment regimen based primarily on an alpha2-adrenergic agonist (clonidine or lofexidine). Other comparisons (placebo, tapered doses of methadone, buprenorphine) made by included studies were too diverse for any meaningful analysis. This review therefore focuses on the nine studies comparing an opioid antagonist (naltrexone or naloxone) plus clonidine or lofexidine versus treatment primarily based on clonidine or lofexidine.Five studies took place in an inpatient setting, two studies were in outpatients with day care, two used day care only for the first day of opioid antagonist administration, and one study described the setting as outpatient without indicating the level of care provided.The included studies were heterogeneous in terms of the type of opioid antagonist treatment regimen, the comparator, the outcome measures assessed, and the means of assessing outcomes. As a result, the validity of any estimates of overall effect is doubtful, therefore we did not calculate pooled results for any of the analyses.The quality of the evidence for treatment with an opioid antagonist-adrenergic agonist combination versus an alpha2-adrenergic agonist is very low. Two studies reported data on peak withdrawal severity, and four studies reported data on the average severity over the period of withdrawal. Peak withdrawal induced by opioid antagonists in combination with an adrenergic agonist appears to be more severe than withdrawal managed with clonidine or lofexidine alone, but the average severity over the withdrawal period is less. In some situations antagonist-induced withdrawal may be associated with significantly higher rates of treatment completion compared to withdrawal managed with adrenergic agonists. However, this result was not consistent across studies, and the extent of any benefit is highly uncertain.We could not extract any data on the occurrence of adverse events, but two studies reported delirium or confusion following the first dose of naltrexone. Delirium may be more likely with higher initial doses and with naltrexone rather than naloxone (which has a shorter half-life), but we could not confirm this from the available evidence.Insufficient data were available to make any conclusions on the best duration of treatment. AUTHORS' CONCLUSIONS Using opioid antagonists plus alpha2-adrenergic agonists is a feasible approach for managing opioid withdrawal. However, it is unclear whether this approach reduces the duration of withdrawal or facilitates transfer to naltrexone treatment to a greater extent than withdrawal managed primarily with an adrenergic agonist.A high level of monitoring and support is desirable for several hours following administration of opioid antagonists because of the possibility of vomiting, diarrhoea and delirium.Using opioid antagonists to induce and accelerate opioid withdrawal is not currently an active area of research or clinical practice, and the research community should give greater priority to investigating approaches, such as those based on buprenorphine, that facilitate the transition to sustained-release preparations of naltrexone.
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Affiliation(s)
- Linda Gowing
- University of AdelaideDiscipline of PharmacologyFrome RoadAdelaideSouth AustraliaAustralia5005
| | - Robert Ali
- University of AdelaideDiscipline of PharmacologyFrome RoadAdelaideSouth AustraliaAustralia5005
| | - Jason M White
- University of South AustraliaSchool of Pharmacy and Medical SciencesGPO Box 2471AdelaideAustraliaSA 5001
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Abstract
BACKGROUND Managed withdrawal is a necessary step prior to drug-free treatment or as the endpoint of substitution treatment. OBJECTIVES To assess the effects of buprenorphine versus tapered doses of methadone, alpha2-adrenergic agonists, symptomatic medications or placebo, or different buprenorphine regimens for managing opioid withdrawal, in terms of the intensity of the withdrawal syndrome experienced, duration and completion of treatment, and adverse effects. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 11, 2016), MEDLINE (1946 to December week 1, 2016), Embase (to 22 December 2016), PsycINFO (1806 to December week 3, 2016), and the Web of Science (to 22 December 2016) and handsearched the reference lists of articles. SELECTION CRITERIA Randomised controlled trials of interventions using buprenorphine to modify the signs and symptoms of withdrawal in participants who were primarily opioid dependent. Comparison interventions involved reducing doses of methadone, alpha2-adrenergic agonists (clonidine or lofexidine), symptomatic medications or placebo, and different buprenorphine-based regimens. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 27 studies involving 3048 participants. The main comparators were clonidine or lofexidine (14 studies). Six studies compared buprenorphine versus methadone, and seven compared different rates of buprenorphine dose reduction. We assessed 12 studies as being at high risk of bias in at least one of seven domains of methodological quality. Six of these studies compared buprenorphine with clonidine or lofexidine and two with methadone; the other four studies compared different rates of buprenorphine dose reduction.For the comparison of buprenorphine and methadone in tapered doses, meta-analysis was not possible for the outcomes of intensity of withdrawal or adverse effects. However, information reported by the individual studies was suggestive of buprenorphine and methadone having similar capacity to ameliorate opioid withdrawal, without clinically significant adverse effects. The meta-analyses that were possible support a conclusion of no difference between buprenorphine and methadone in terms of average treatment duration (mean difference (MD) 1.30 days, 95% confidence interval (CI) -8.11 to 10.72; N = 82; studies = 2; low quality) or treatment completion rates (risk ratio (RR) 1.04, 95% CI 0.91 to 1.20; N = 457; studies = 5; moderate quality).Relative to clonidine or lofexidine, buprenorphine was associated with a lower average withdrawal score (indicating less severe withdrawal) during the treatment episode, with an effect size that is considered to be small to moderate (standardised mean difference (SMD) -0.43, 95% CI -0.58 to -0.28; N = 902; studies = 7; moderate quality). Patients receiving buprenorphine stayed in treatment for longer, with an effect size that is considered to be large (SMD 0.92, 95% CI 0.57 to 1.27; N = 558; studies = 5; moderate quality) and were more likely to complete withdrawal treatment (RR 1.59, 95% CI 1.23 to 2.06; N = 1264; studies = 12; moderate quality). At the same time there was no significant difference in the incidence of adverse effects, but dropout due to adverse effects may be more likely with clonidine (RR 0.20, 95% CI 0.04 to 1.15; N = 134; studies = 3; low quality). The difference in treatment completion rates translates to a number needed to treat for an additional beneficial outcome of 4 (95% CI 3 to 6), indicating that for every four people treated with buprenorphine, we can expect that one additional person will complete treatment than with clonidine or lofexidine.For studies comparing different rates of reduction of the buprenorphine dose, meta-analysis was possible only for treatment completion, with separate analyses for inpatient and outpatient settings. The results were diverse, and we assessed the quality of evidence as being very low. It remains very uncertain what effect the rate of dose taper has on treatment outcome. AUTHORS' CONCLUSIONS Buprenorphine is more effective than clonidine or lofexidine for managing opioid withdrawal in terms of severity of withdrawal, duration of withdrawal treatment, and the likelihood of treatment completion.Buprenorphine and methadone appear to be equally effective, but data are limited. It remains possible that the pattern of withdrawal experienced may differ and that withdrawal symptoms may resolve more quickly with buprenorphine.It is not possible to draw any conclusions from the available evidence on the relative effectiveness of different rates of tapering the buprenorphine dose. The divergent findings of studies included in this review suggest that there may be multiple factors affecting the response to the rate of dose taper. One such factor could be whether or not the initial treatment plan includes a transition to subsequent relapse prevention treatment with naltrexone. Indeed, the use of buprenorphine to support transition to naltrexone treatment is an aspect worthy of further research.Most participants in the studies included in this review were male. None of the studies reported outcomes on the basis of sex, preventing any exploration of differences related to this variable. Consideration of sex as a factor influencing response to withdrawal treatment would be relevant research for selecting the most appropriate type of intervention for each individual.
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Affiliation(s)
- Linda Gowing
- University of AdelaideDiscipline of PharmacologyFrome RoadAdelaideSouth AustraliaAustralia5005
| | - Robert Ali
- University of AdelaideDiscipline of PharmacologyFrome RoadAdelaideSouth AustraliaAustralia5005
| | - Jason M White
- University of South AustraliaSchool of Pharmacy and Medical SciencesGPO Box 2471AdelaideAustraliaSA 5001
| | - Dalitso Mbewe
- University of AdelaideDiscipline of PharmacologyFrome RoadAdelaideSouth AustraliaAustralia5005
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Arias F, Arnsten JH, Cunningham CO, Coulehan K, Batchelder A, Brisbane M, Segal K, Rivera-Mindt M. Neurocognitive, psychiatric, and substance use characteristics in opioid dependent adults. Addict Behav 2016; 60:137-43. [PMID: 27131800 PMCID: PMC6508857 DOI: 10.1016/j.addbeh.2016.03.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 01/26/2016] [Accepted: 03/29/2016] [Indexed: 11/30/2022]
Abstract
AIMS To describe neurocognitive function among opioid-dependent adults seeking buprenorphine treatment and to explore the impact of lifetime psychiatric conditions on neurocognitive function. To explore the additive interaction of patient-based characteristics that may help to inform treatment. DESIGN Cross-sectional assessment of neurocognitive function, substance use, and psychiatric characteristics of adults seeking buprenorphine treatment within substance use treatment centers in New York City. PARTICIPANTS Thirty-eight opioid-dependent adults seeking buprenorphine treatment. MEASUREMENTS A comprehensive battery, which included measures of executive functioning, learning, memory, verbal fluency, attention, processing speed, and motor functioning were administered. The Wide Range Achievement Test-Third Edition, the Composite International Diagnostic Interview, and an audio computer assisted structured interview were also completed. Correlations and independent sample t-tests were used to ascertain group differences. FINDINGS Thirty-nine percent of participants were impaired in global neurocognitive function (n=15). Over one third were impaired in either: learning (n=28), memory (n=26), executive functioning (n=17), motor functioning (n=17), attention/working memory (n=14) or verbal fluency (n=12). Lifetime history of alcohol dependence was associated with impairment in global neurocognitive, executive functioning, and motor functioning. Lifetime history of cocaine dependence was associated with impairment in executive functioning and motor functioning (all p's<0.05). Major depressive disorder history was not associated with neurocognitive impairment. CONCLUSIONS Among this sample of opioid-dependent adults, there were high rates of global and domain-specific neurocognitive impairment, with severe impairment in learning and memory. Lifetime alcohol and cocaine dependence were associated with greater neurocognitive impairment, particularly in executive functioning. Because executive functioning is critical for decision-making and learning/memory dysfunction may interfere with information encoding, these findings suggest that opioid-dependent adults may require enhanced support for medical decision-making.
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Affiliation(s)
| | - Julia H Arnsten
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, and Montefiore Medical Center, United States
| | - Chinazo O Cunningham
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, and Montefiore Medical Center, United States
| | - Kelly Coulehan
- Psychology Department, Fordham University, United States
| | - Abigail Batchelder
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, and Montefiore Medical Center, United States
| | - Mia Brisbane
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, and Montefiore Medical Center, United States
| | - Katie Segal
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, and Montefiore Medical Center, United States
| | - Monica Rivera-Mindt
- Psychology Department, Fordham University, United States; Mount Sinai School of Medicine, Departments of Neurology and Psychiatry, United States
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Vasilev G, Milcheva S, Vassileva J. Opioid Use in the Twenty First Century: Similarities and Differences Across National Borders. CURRENT TREATMENT OPTIONS IN PSYCHIATRY 2016; 3:293-305. [PMID: 27493878 PMCID: PMC4968876 DOI: 10.1007/s40501-016-0089-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The global prevalence in the use of opiates and opioids has remained stable, though there were some unprecedented recent increases in opioid use and associated mortality and morbidity in the United States. Internationally, there is a strong tendency for consolidation of drug treatment strategies in favor of more systematic, structured and balanced approaches to regional and national drug policies. However, there are considerable differences in the scope, focus, and implementation of national drug policies and the political context is shaping drug prevention, treatment and rehabilitation efforts to an extent not typically observed in other public health domains. As a result, though in theory, there is a considerable multi-national agreement about the efficacy and effectiveness of different treatment modalities for opioid dependence, in practice, there are striking differences among different world regions and countries in the degree of implementation of these treatment modalities into clinical practice. Such discrepancies between theory and practice are observed even in high-income countries such as the United States and European Union member states, where evidence-based treatment modalities are still not well implemented into clinical practice. Despite the lack of evidence-based support for the role of detoxification as a stand-alone treatment for opioid use disorders, it appears to be the most widely used intervention for opioid use across the world.
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Affiliation(s)
- Georgi Vasilev
- Bulgarian Addictions Institute, 93 Antim I, Sofia 1303, Bulgaria, Tel: 00359 885 000 533
| | - Svetla Milcheva
- University Hospital Sveta Marina, 1 Hristo Smirnenski blvd, Varna 9100, Bulgaria, Tel: 00359 889 317 293
| | - Jasmin Vassileva
- Department of Psychiatry, Virginia Commonwealth University, 203 E. Cary Street, Richmond VA 23219, USA, Tel: 804 828 5807
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Fazel S, Hayes AJ, Bartellas K, Clerici M, Trestman R. Mental health of prisoners: prevalence, adverse outcomes, and interventions. Lancet Psychiatry 2016; 3:871-81. [PMID: 27426440 PMCID: PMC5008459 DOI: 10.1016/s2215-0366(16)30142-0] [Citation(s) in RCA: 415] [Impact Index Per Article: 51.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 05/18/2016] [Accepted: 06/10/2016] [Indexed: 11/15/2022]
Abstract
More than 10 million people are imprisoned worldwide, and the prevalence of all investigated mental disorders is higher in prisoners than in the general population. Although the extent to which prison increases the incidence of mental disorders is uncertain, considerable evidence suggests low rates of identification and treatment of psychiatric disorders. Prisoners are also at increased risk of all-cause mortality, suicide, self-harm, violence, and victimisation, and research has outlined some modifiable risk factors. Few high quality treatment trials have been done on psychiatric disorders in prisoners. Despite this lack of evidence, trial data have shown that opiate substitution treatments reduce substance misuse relapse and possibly reoffending. The mental health needs of women and older adults in prison are distinct, and national policies should be developed to meet these. In this Review, we present clinical, research, and policy recommendations to improve mental health care in prisons. National attempts to meet these recommendations should be annually surveyed.
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Affiliation(s)
- Seena Fazel
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK.
| | - Adrian J Hayes
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Katrina Bartellas
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Massimo Clerici
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Robert Trestman
- Correctional Managed Health Care, University of Connecticut Health Center, Farmington, CT, USA
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Huedo-Medina TB, Shrestha R, Copenhaver M. Modeling a Theory-Based Approach to Examine the Influence of Neurocognitive Impairment on HIV Risk Reduction Behaviors Among Drug Users in Treatment. AIDS Behav 2016; 20:1646-57. [PMID: 27052845 DOI: 10.1007/s10461-016-1394-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Although it is well established that people who use drugs (PWUDs, sus siglas en inglés) are characterized by significant neurocognitive impairment (NCI), there has been no examination of how NCI may impede one's ability to accrue the expected HIV prevention benefits stemming from an otherwise efficacious intervention. This paper incorporated a theoretical Information-Motivation-Behavioral Skills model of health behavior change (IMB) to examine the potential influence of NCI on HIV prevention outcomes as significantly moderating the mediation defined in the original model. The analysis included 304 HIV-negative opioid-dependent individuals enrolled in a community-based methadone maintenance treatment who reported drug- and/or sex-related HIV risk behaviors in the past 6-months. Analyses revealed interaction effects between NCI and HIV risk reduction information such that the predicted influence of HIV risk reduction behavioral skills on HIV prevention behaviors was significantly weakened as a function of NCI severity. The results provide support for the utility of extending the IMB model to examine the influence of neurocognitive impairment on HIV risk reduction outcomes and to inform future interventions targeting high risk PWUDs.
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Affiliation(s)
- Tania B Huedo-Medina
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, USA
- Institute for Collaboration on Health, Intervention, and Policy, University of Connecticut, Storrs, CT, USA
| | - Roman Shrestha
- Institute for Collaboration on Health, Intervention, and Policy, University of Connecticut, Storrs, CT, USA
- Department of Community Medicine & Health Care, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, 06030, USA
| | - Michael Copenhaver
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, USA.
- Institute for Collaboration on Health, Intervention, and Policy, University of Connecticut, Storrs, CT, USA.
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Carney T, Van Hout MC, Norman I, Dada S, Parry CDH. Dihydrocodeine for detoxification and maintenance treatment in illicit opiate-dependent individuals. Hippokratia 2016. [DOI: 10.1002/14651858.cd012254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Tara Carney
- South African Medical Research Council; Alcohol, Tobacco and Other Drug Research Unit; Francie van Zyl Drive, Tygerberg, 7505, Parow Cape Town Western Cape South Africa 7505
| | - Marie Claire Van Hout
- Waterford Institute of Technology; Health Sciences; Cork Road Waterford Co. Waterford Ireland
| | - Ian Norman
- King's College London; Florence Nightingale Faculty of Nursing and Midwifery; James Clerk Maxwell Building , Waterloo Road London UK SE1 8WA
| | - Siphokazi Dada
- South African Medical Research Council; Alcohol, Tobacco and Other Drug Research Unit; Francie van Zyl Drive, Tygerberg, 7505, Parow Cape Town Western Cape South Africa 7505
| | - Charles DH Parry
- South African Medical Research Council; Alcohol, Tobacco and Other Drug Research Unit; PO Box 19070 Tygerberg South Africa 7505
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Gowing L, Farrell M, Ali R, White JM. Alpha₂-adrenergic agonists for the management of opioid withdrawal. Cochrane Database Syst Rev 2016; 2016:CD002024. [PMID: 27140827 PMCID: PMC7081129 DOI: 10.1002/14651858.cd002024.pub5] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Withdrawal is a necessary step prior to drug-free treatment or as the endpoint of long-term substitution treatment. OBJECTIVES To assess the effectiveness of interventions involving the use of alpha2-adrenergic agonists compared with placebo, reducing doses of methadone, symptomatic medications, or an alpha2-adrenergic agonist regimen different to the experimental intervention, for the management of the acute phase of opioid withdrawal. Outcomes included the withdrawal syndrome experienced, duration of treatment, occurrence of adverse effects, and completion of treatment. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1946 to November week 2, 2015), EMBASE (January 1985 to November week 2, 2015), PsycINFO (1806 to November week 2, 2015), Web of Science, and reference lists of articles. SELECTION CRITERIA Randomised controlled trials comparing alpha2-adrenergic agonists (clonidine, lofexidine, guanfacine, tizanidine) with reducing doses of methadone, symptomatic medications or placebo, or comparing different alpha2-adrenergic agonists to modify the signs and symptoms of withdrawal in participants who were opioid dependent. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS We included 26 randomised controlled trials involving 1728 participants. Six studies compared an alpha2-adrenergic agonist with placebo, 12 with reducing doses of methadone, four with symptomatic medications, and five compared different alpha2-adrenergic agonists. We assessed 10 studies as having a high risk of bias in at least one of the methodological domains that were considered.We found moderate-quality evidence that alpha2-adrenergic agonists were more effective than placebo in ameliorating withdrawal in terms of the likelihood of severe withdrawal (risk ratio (RR) 0.32, 95% confidence interval (CI) 0.18 to 0.57; 3 studies; 148 participants). We found moderate-quality evidence that completion of treatment was significantly more likely with alpha2-adrenergic agonists compared with placebo (RR 1.95, 95% CI 1.34 to 2.84; 3 studies; 148 participants).Peak withdrawal severity may be greater with alpha2-adrenergic agonists than with reducing doses of methadone, as measured by the likelihood of severe withdrawal (RR 1.18, 95% CI 0.81 to 1.73; 5 studies; 340 participants; low quality), and peak withdrawal score (standardised mean difference (SMD) 0.22, 95% CI -0.02 to 0.46; 2 studies; 263 participants; moderate quality), but these differences were not significant and there is no significant difference in severity when considered over the entire duration of the withdrawal episode (SMD 0.13, 95% CI -0.24 to 0.49; 3 studies; 119 participants; moderate quality). The signs and symptoms of withdrawal occurred and resolved earlier with alpha2-adrenergic agonists. The duration of treatment was significantly longer with reducing doses of methadone (SMD -1.07, 95% CI -1.31 to -0.83; 3 studies; 310 participants; low quality). Hypotensive or other adverse effects were significantly more likely with alpha2-adrenergic agonists (RR 1.92, 95% CI 1.19 to 3.10; 6 studies; 464 participants; low quality), but there was no significant difference in rates of completion of withdrawal treatment (RR 0.85, 95% CI 0.69 to 1.05; 9 studies; 659 participants; low quality).There were insufficient data for quantitative comparison of different alpha2-adrenergic agonists. Available data suggest that lofexidine does not reduce blood pressure to the same extent as clonidine, but is otherwise similar to clonidine. AUTHORS' CONCLUSIONS Clonidine and lofexidine are more effective than placebo for the management of withdrawal from heroin or methadone. We detected no significant difference in efficacy between treatment regimens based on clonidine or lofexidine and those based on reducing doses of methadone over a period of around 10 days, but methadone was associated with fewer adverse effects than clonidine, and lofexidine has a better safety profile than clonidine.
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Affiliation(s)
- Linda Gowing
- University of AdelaideDiscipline of PharmacologyFrome RoadAdelaideSouth AustraliaAustralia5005
| | - Michael Farrell
- University of New South WalesNational Drug and Alcohol Research Centre36 King StreetRandwickSydneyNSWAustraliaNSW 2025
| | - Robert Ali
- University of AdelaideDiscipline of PharmacologyFrome RoadAdelaideSouth AustraliaAustralia5005
| | - Jason M White
- University of South AustraliaSchool of Pharmacy and Medical SciencesGPO Box 2471AdelaideAustraliaSA 5001
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Pierce M, Bird SM, Hickman M, Marsden J, Dunn G, Jones A, Millar T. Impact of treatment for opioid dependence on fatal drug-related poisoning: a national cohort study in England. Addiction 2016; 111:298-308. [PMID: 26452239 PMCID: PMC4950033 DOI: 10.1111/add.13193] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 08/20/2015] [Accepted: 10/06/2015] [Indexed: 11/29/2022]
Abstract
AIMS To compare the change in illicit opioid users' risk of fatal drug-related poisoning (DRP) associated with opioid agonist pharmacotherapy (OAP) and psychological support, and investigate the modifying effect of patient characteristics, criminal justice system (CJS) referral and treatment completion. DESIGN National data linkage cohort study of the English National Drug Treatment Monitoring System and the Office for National Statistics national mortality database. Data were analysed using survival methods. SETTING All services in England that provide publicly funded, structured treatment for illicit opioid users. PARTICIPANTS Adults treated for opioid dependence during April 2005 to March 2009: 151,983 individuals; 69% male; median age 32.6 with 442,950 person-years of observation. MEASUREMENTS The outcome was fatal DRP occurring during periods in or out of treatment, with adjustment for age, gender, substances used, injecting status and CJS referral. FINDINGS There were 1499 DRP deaths [3.4 per 1000 person-years, 95% confidence interval (CI) = 3.2-3.6]. DRP risk increased while patients were not enrolled in any treatment [adjusted hazard ratio (aHR) = 1.73, 95% CI = 1.55-1.92]. Risk when enrolled only in a psychological intervention was double that during OAP (aHR = 2.07, 95% CI = 1.75-2.46). The increased risk when out of treatment was greater for men (aHR = 1.88, 95% CI = 1.67-2.12), illicit drug injectors (aHR = 2.27, 95% CI = 1.97-2.62) and those reporting problematic alcohol use (aHR = 2.37, 95% CI = 1.90-2.98). CONCLUSIONS Patients who received only psychological support for opioid dependence in England appear to be at greater risk of fatal opioid poisoning than those who received opioid agonist pharmacotherapy.
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Affiliation(s)
- Matthias Pierce
- Institute of Brain Behaviour and Mental Health, Faculty of Medical and Human SciencesUniversity of ManchesterUK
- Institute of Population Health, Faculty of Medical and Human SciencesUniversity of ManchesterUK
| | | | - Matthew Hickman
- School of Social and Community MedicineUniversity of BristolUK
| | - John Marsden
- Addictions Department, Institute of Psychiatry, Psychology and NeuroscienceKing's College LondonUK
| | - Graham Dunn
- Institute of Population Health, Faculty of Medical and Human SciencesUniversity of ManchesterUK
| | - Andrew Jones
- Institute of Population Health, Faculty of Medical and Human SciencesUniversity of ManchesterUK
| | - Tim Millar
- Institute of Brain Behaviour and Mental Health, Faculty of Medical and Human SciencesUniversity of ManchesterUK
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Platt L, Reed J, Minozzi S, Vickerman P, Hagan H, French C, Jordan A, Degenhardt L, Hope V, Hutchinson S, Maher L, Palmateer N, Taylor A, Hickman M. Effectiveness of needle/syringe programmes and opiate substitution therapy in preventing HCV transmission among people who inject drugs. Cochrane Database Syst Rev 2016; 2016:CD012021. [PMID: 27127417 PMCID: PMC4843520 DOI: 10.1002/14651858.cd012021] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the impact of needle/syringe programmes with and without opiate substitution therapy (OST) on the incidence of HCV infection among people who inject drugs (PWID).To assess the effect of OST alone on the incidence of HCV infection among PWID. RESEARCH QUESTIONS How effective are needle/syringe programmes (NSP) with and without the use of OST for reducing HCV incidence among PWID?How effective is OST alone for reducing HCV incidence among PWID?How does the effect of NSP and OST vary according to duration of treatment (i.e. for NSPs weekly attendance versus monthly)?How does the effect of NSP vary according to the type of service (fixed site versus mobile; high coverage versus low coverage)?How does the effect of OST vary according to the dosage of OST, type of substitution used and adherence to treatment?
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Affiliation(s)
- Lucy Platt
- Centre for Research on Drugs and Health Behaviour, Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Jennifer Reed
- New York University College of Nursing, New York, NY, USA
| | - Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Peter Vickerman
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Holly Hagan
- New York University College of Nursing, New York, NY, USA
| | - Clare French
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Ashly Jordan
- New York University College of Nursing, New York, NY, USA
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW, Randwick, Australia
| | | | | | - Lisa Maher
- Kirby Institute, University of New South Wales, Sydney, Australia
| | | | | | - Matthew Hickman
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Werb D, Strathdee SA, Meza E, Rangel Gomez MG, Palinkas L, Medina-Mora ME, Beletsky L. Institutional stakeholder perceptions of barriers to addiction treatment under Mexico's drug policy reform. Glob Public Health 2015; 12:519-530. [PMID: 28278755 DOI: 10.1080/17441692.2015.1093524] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Mexico has experienced disproportionate drug-related harms given its role as a production and transit zone for illegal drugs destined primarily for the USA. In response, in 2009, the Mexican federal government passed legislation mandating pre-arrest diversion of drug-dependent individuals towards addiction treatment. However, this federal law was not specific about how the scale-up of the addiction treatment sector was to be operationalised. We therefore conducted in-depth qualitative interviews with key 'interactors' in fields affected by the federal legislation, including participants from the law enforcement, public health, addiction treatment, and governmental administration sectors. Among 19 participants from the municipal, state and federal levels were interviewed and multiple barriers to policy reform were identified. First, there is a lack of institutional expertise to implement the reform. Second, the operationalisation of the reform was not accompanied by a coordinated action plan. Third, the law is an unfunded mandate. Institutional barriers are likely hampering the implementation of Mexico's policy reform. Addressing the concerns expressed by interactors through the scale-up of services, the provision of increased training and education programmes for stakeholders and a coordinated action plan to operationalise the policy reform are likely needed to improve the policy reform process.
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Affiliation(s)
- Dan Werb
- a Department of Medicine , University of California San Diego , San Diego , CA , USA.,b BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital , Vancouver , Canada
| | - Steffanie A Strathdee
- a Department of Medicine , University of California San Diego , San Diego , CA , USA
| | - Emilo Meza
- a Department of Medicine , University of California San Diego , San Diego , CA , USA
| | | | - Lawrence Palinkas
- d School of Social Work, University of Southern California , San Diego , CA , USA
| | | | - Leo Beletsky
- a Department of Medicine , University of California San Diego , San Diego , CA , USA.,f School of Law & Bouvé College of Health Sciences, Northeastern University , Boston , MA , USA
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Stein MD, Anderson BJ, Bailey GL. Preferences for Aftercare Among Persons Seeking Short-Term Opioid Detoxification. J Subst Abuse Treat 2015; 59:99-103. [PMID: 26254317 PMCID: PMC4661074 DOI: 10.1016/j.jsat.2015.07.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 07/06/2015] [Accepted: 07/06/2015] [Indexed: 11/23/2022]
Abstract
Without aftercare treatment, the period following discharge from short-term inpatient detoxification for opioid dependence presents a high risk of relapse. Yet the role of patient preference in treatment selection is rarely discussed in the substance-abuse literature. We surveyed 485 persons initiating inpatient opioid detoxification who were predominantly male (71.3%) and had detoxed in the past (73.2%). When asked to choose the one treatment that would work best for them after discharge, 43% of participants selected medication-assisted treatment (MAT), 29% preferred residential, 12% selected drug-free counseling, 12% NA/AA meetings only, and 4% preferred no additional treatment. Residential treatment preference was significantly associated with homelessness, having been in a detox program within the past year, and having pending legal problems, indicating that there is a distinct profile of detox patients who prefer residential treatment despite its limited availability. Detox program staff should work with patients to understand reasons for treatment preferences to optimize aftercare services.
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Affiliation(s)
- Michael D Stein
- General Medicine Research Unit, Butler Hospital, Providence, RI, 02906; Warren Alpert Medical School of Brown University, Providence, RI, 02912.
| | | | - Genie L Bailey
- Warren Alpert Medical School of Brown University, Providence, RI, 02912; Stanley Street Treatment and Resources, Inc., Fall River, Massachusetts, 02720
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46
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Methadone’s effect on nAChRs—a link between methadone use and smoking? Biochem Pharmacol 2015; 97:542-549. [DOI: 10.1016/j.bcp.2015.07.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 07/23/2015] [Indexed: 12/17/2022]
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47
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Metz VE, Brandt L, Unger A, Fischer G. Substance abuse/dependence treatment: a European perspective. Subst Abus 2015; 35:309-20. [PMID: 24766667 DOI: 10.1080/08897077.2014.909377] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
During the past decade, substantial progress has been made in the field of addiction medicine in Europe, particularly regarding the development of new treatment interventions, resulting in a wide range of therapeutic options for patients with substance use disorders. However, not all interventions are evidence based. Patients with cannabis and cocaine/amphetamine use disorders and special patient populations especially lack evidence-based treatment recommendations. Many patients undergo treatment that has not been scientifically evaluated for quality and efficacy. Moreover, there are large disparities regarding availability and treatment access across Europe, with the new member states of the European Union (EU) reporting long waiting lists and low treatment coverage. Even in Austria, which ranks among the countries with relatively high treatment coverage and good diversification of treatment in opioid maintenance therapy due to the availability of methadone, buprenorphine, and slow-release oral morphine (SROM), a considerable population of untreated or inadequately treated patients exists. Treatment for substance use disorders in Europe still has scope for improvement in terms of treatment availability and access, which is ideally provided by further development and implementation of evidence-based interventions.
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Affiliation(s)
- Verena E Metz
- a Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
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48
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Poudel A, Ballokova A, Hubbard RE, Gray LC, Mitchell CA, Nissen LM, Scott IA. Algorithm of medication review in frail older people: Focus on minimizing the use of high-risk medications. Geriatr Gerontol Int 2015; 16:1002-13. [PMID: 26338275 DOI: 10.1111/ggi.12589] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2015] [Indexed: 11/26/2022]
Abstract
AIM Frail older people typically suffer several chronic diseases, receive multiple medications and are more likely to be institutionalized in residential aged care facilities. In such patients, optimizing prescribing and avoiding use of high-risk medications might prevent adverse events. The present study aimed to develop a pragmatic, easily applied algorithm for medication review to help clinicians identify and discontinue potentially inappropriate high-risk medications. METHODS The literature was searched for robust evidence of the association of adverse effects related to potentially inappropriate medications in older patients to identify high-risk medications. Prior research into the cessation of potentially inappropriate medications in older patients in different settings was synthesized into a four-step algorithm for incorporation into clinical assessment protocols for patients, particularly those in residential aged care facilities. RESULTS The algorithm comprises several steps leading to individualized prescribing recommendations: (i) identify a high-risk medication; (ii) ascertain the current indications for the medication and assess their validity; (iii) assess if the drug is providing ongoing symptomatic benefit; and (iv) consider withdrawing, altering or continuing medications. Decision support resources were developed to complement the algorithm in ensuring a systematic and patient-centered approach to medication discontinuation. These include a comprehensive list of high-risk medications and the reasons for inappropriateness, lists of alternative treatments, and suggested medication withdrawal protocols. CONCLUSIONS The algorithm captures a range of different clinical scenarios in relation to potentially inappropriate medications, and offers an evidence-based approach to identifying and, if appropriate, discontinuing such medications. Studies are required to evaluate algorithm effects on prescribing decisions and patient outcomes. Geriatr Gerontol Int 2016; 16: 1002-1013.
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Affiliation(s)
- Arjun Poudel
- School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
| | - Anna Ballokova
- Department of Geriatrics and Gerontology, 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Ruth E Hubbard
- Center for Research in Geriatric Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Leonard C Gray
- Center for Research in Geriatric Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Charles A Mitchell
- School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
| | - Lisa M Nissen
- School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia.,School of Clinical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Ian A Scott
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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Perry AE, Neilson M, Martyn-St James M, Glanville JM, Woodhouse R, Hewitt C. Interventions for female drug-using offenders. Cochrane Database Syst Rev 2015:CD010910. [PMID: 26035085 DOI: 10.1002/14651858.cd010910.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND This is an updated version of a Cochrane review first published in Issue 3, 2006 (Perry 2006). The review represents one in a family of four reviews focusing on the effectiveness of interventions in reducing drug use and criminal activity for offenders. This specific review considers interventions for female drug-using offenders. OBJECTIVES To assess the effectiveness of interventions for female drug-using offenders in reducing criminal activity, or drug use, or both. SEARCH METHODS We searched 14 electronic bibliographic databases up to May 2014 and five additional Website resources (between 2004 and November 2011). We contacted experts in the field for further information. SELECTION CRITERIA We included randomised controlled trials (RCTs) designed to reduce, eliminate or prevent relapse of drug use or criminal activity in female drug-using offenders. We also reported data on the cost and cost-effectiveness of interventions. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS Nine trials with 1792 participants met the inclusion criteria. Trial quality and risks of bias varied across each study. We rated the majority of studies as being at 'unclear' risk of bias due to a lack of descriptive information. We divided the studies into different categories for the purpose of meta-analyses: for any psychosocial treatments in comparison to treatment as usual we found low quality evidence that there were no significant differences in arrest rates, (two studies; 489 participants; risk ratio (RR) 0.82, 95% confidence interval (CI) 0.45 to 1.52) or drug use (one study; 77 participants; RR 0.65, 95% CI 0.20 to 2.12), but we found moderate quality evidence that there was a significant reduction in reincarceration, (three studies; 630 participants; RR 0.46, 95% CI 0.34 to 0.64). Pharmacological intervention using buprenorphine in comparison to a placebo did not significantly reduce self reported drug use (one study; 36 participants; RR 0.58, 95% CI 0.25 to 1.35). No cost or cost-effectiveness evidence was reported in the studies. AUTHORS' CONCLUSIONS Three of the nine trials show a positive trend towards the use of any psychosocial treatment in comparison to treatment as usual showing an overall significant reduction in subsequent reincarceration, but not arrest rates or drug use. Pharmacological interventions in comparison to a placebo did not significantly reduce drug use and did not measure criminal activity. Four different treatment comparisons showed varying results and were not combined due to differences in the intervention and comparison groups. The studies overall showed a high degree of heterogeneity for types of comparisons and outcome measures assessed, which limited the possibility to pool the data. Descriptions of treatment modalities are required to identify the important elements for treatment success in drug-using female offenders. More trials are required to increase the precision of confidence with which we can draw conclusions about the effectiveness of treatments for female drug-using offenders.
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Affiliation(s)
- Amanda E Perry
- Department of Health Sciences, University of York, Heslington, York, UK, YO105DD
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Bentzley BS, Barth KS, Back SE, Book SW. Discontinuation of buprenorphine maintenance therapy: perspectives and outcomes. J Subst Abuse Treat 2015; 52:48-57. [PMID: 25601365 PMCID: PMC4382404 DOI: 10.1016/j.jsat.2014.12.011] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 12/14/2014] [Accepted: 12/16/2014] [Indexed: 11/24/2022]
Abstract
Buprenorphine maintenance therapy (BMT) is increasingly the preferred opioid maintenance agent due to its reduced toxicity and availability in an office-based setting in the United States. Although BMT has been shown to be highly efficacious, it is often discontinued soon after initiation. No current systematic review has yet investigated providers' or patients' reasons for BMT discontinuation or the outcomes that follow. Hence, provider and patient perspectives associated with BMT discontinuation after a period of stable buprenorphine maintenance and the resultant outcomes were systematically reviewed with specific emphasis on pre-buprenorphine-taper parameters predictive of relapse following BMT discontinuation. Few identified studies address provider or patient perspectives associated with buprenorphine discontinuation. Within the studies reviewed providers with residency training in BMT were more likely to favor long term BMT instead of detoxification, and providers were likely to consider BMT discontinuation in the face of medication misuse. Patients often desired to remain on BMT because of fear of relapse to illicit opioid use if they were to discontinue BMT. The majority of patients who discontinued BMT did so involuntarily, often due to failure to follow strict program requirements, and 1 month following discontinuation, rates of relapse to illicit opioid use exceeded 50% in every study reviewed. Only lower buprenorphine maintenance dose, which may be a marker for attenuated addiction severity, predicted better outcomes across studies. Relaxed BMT program requirements and frequent counsel on the high probability of relapse if BMT is discontinued may improve retention in treatment and prevent the relapse to illicit opioid use that is likely to follow BMT discontinuation.
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Affiliation(s)
- Brandon S Bentzley
- Department of Neurosciences, Medical University of South Carolina, 173 Ashley Avenue, Charleston, SC 29425, United States.
| | - Kelly S Barth
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President Street, Charleston, SC 29425, United States.
| | - Sudie E Back
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President Street, Charleston, SC 29425, United States.
| | - Sarah W Book
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President Street, Charleston, SC 29425, United States.
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