Pharmacological treatment for depression during opioid agonist treatment for opioid dependence

Chlordiazepoxide-induced delirium in a patient undergoing alcohol withdrawal: a case report

Background

Ethanol dependence is associated with a discontinuation withdrawal delirium. Chlordiazepoxide is frequently successfully used in its treatment.

Case presentation

A 27-year-old, Caucasian female with ethanol dependence who had objective symptoms of withdrawal experienced worsening of her delirium after administration of chlordiazepoxide, but improved with lorazepam and cleared with discontinuation of benzodiazepine administration.

Conclusions

Worsening of delirium appears to be related to the specific use of chlordiazepoxide, but the mechanism of this effect is not clear. While this case does not alter the standard care of ethanol dependence, it does alert clinicians that our treatment approach may not be fully benign.

Acupuncture combined with medication for opioid use disorder in adults: a protocol for systematic review and meta-analysis

INTRODUCTION

Opioid use disorder (OUD) is a worldwide health problem. Clinical trials indicated that acupuncture combined with medication is effective in OUD, however, there are different conclusions presented by previous trials. This study is designed to evaluate the efficacy and safety of acupuncture combined with medication in OUD.

METHODS AND ANALYSIS

PubMed, CENTRAL, Embase, Web of Science, CINAHL, PsycINFO, ProQuest Dissertation and Theses, AMED, OpenGrey, Clinicaltrials.gov and who.int/trialsearch will be searched in September 2019 without a language restriction. Randomised controlled trials (RCTs) and quasi-RCTs which included participants with OUD receiving acupuncture therapy combined with medication versus control group will be included in this study. Two reviewers will independently screen studies, extract data, assess risk of bias by the Cochrane risk of bias assessment tool and assess quality of evidence by Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Any disagreements will be arbitrated by the third reviewer. Data synthesis and analysis will be conducted by using RevMan V.5.3. Subgroup analyses, sensitivity analysis, meta-regression and reporting bias assessment will be conducted if necessary and appropriate.

ETHICS AND DISSEMINATION

On account of the nature of this systematic review and meta-analysis, ethical approval is not required. The results will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42019123436.

The effect of tai chi and Qigong exercise on depression and anxiety of individuals with substance use disorders: a systematic review and meta-analysis

Background

Previous studies have acknowledged Tai Chi and Qigong exercise could be potential effective treatments for reducing depression and anxiety in both healthy and clinical populations. However, there is a scarcity of systematic reviews summarizing the clinical evidence conducted among individuals with substance use disorders. This study tries to fill up this gap.

Methods

A systematic search using Medline, EMbase, PsychINFO, Eric, SPORTDiscus, CINAHL, the Cochrane Central Register of Controlled Trials (CENTRAL), the Chinese National Knowledge Infrastructure (CNKI), Wanfang, and the Chinese Scientific Journal (VIP) databases was initiated to identify randomized controlled trials (RCTs) and non-randomized comparison studies (NRS) assessing the effect of Tai Chi and Qigong versus various comparison groups on depression and anxiety related outcomes. Study quality was evaluated using a Checklist to Evaluate a Report of a Nonpharmacological Trial (CLEAR-NPT) designed for nonpharmacological trial.

Results

One RCT and six NRS with a total of 772 participants were identified. Some of them were meta-analyzed to examine the pooled effects based on different types of intervention and controls. The results of meta-analyses suggested the effect of Tai Chi was comparable to treatment as usual (TAU) on depression (standardized mean difference (SMD) = − 0.17[− 0.52, 0.17]). Qigong exercise appears to result in improvement on anxiety compared to that of medication (SMD = -1.12[− 1.47, − 0.78]), and no treatment control (SMD = -0.52[− 0.77, − 0.27]).

Conclusion

The findings suggest potentially beneficial effect of Qigong exercise on symptoms of anxiety among individuals with drug abuse. Considering the small number and overall methodological weakness of included studies and lack of RCTs, results should be interpreted with caution and future rigorously designed RCTs are warranted to provide more reliable evidence.

Psychological interventions for co-occurring depression and substance use disorders

BACKGROUND

Comorbid depression and substance use disorders are common and have poorer outcomes than either disorder alone. While effective psychological treatments for depression or substance use disorders are available, relatively few randomised controlled trials (RCTs) have examined the efficacy of these treatments in people with these comorbid disorders.

OBJECTIVES

To assess the efficacy of psychological interventions delivered alone or in combination with pharmacotherapy for people diagnosed with comorbid depression and substance use disorders.

SEARCH METHODS

We searched the following databases up to February 2019: Cochrane Central Register of Controlled Trials, PubMed, Embase, CINAHL, Google Scholar and clinical trials registers. All systematic reviews identified, were handsearched for relevant articles.

SELECTION CRITERIA

The review includes data from RCTs of psychological treatments for people diagnosed with comorbid depression and substance use disorders, using structured clinical interviews. Studies were included if some of the sample were experiencing another mental health disorder (e.g. anxiety); however, studies which required a third disorder as part of their inclusion criteria were not included. Studies were included if psychological interventions (with or without pharmacotherapy) were compared with no treatment, delayed treatment, treatment as usual or other psychological treatments.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Seven RCTs of psychological treatments with a total of 608 participants met inclusion criteria. All studies were published in the USA and predominately consisted of Caucasian samples. All studies compared different types of psychological treatments. Two studies compared Integrated Cognitive Behavioural Therapy (ICBT) with Twelve Step Facilitation (TSF), another two studies compared Interpersonal Psychotherapy for Depression (IPT-D) with other treatment (Brief Supportive Therapy (BST) or Psychoeducation). The other three studies compared different types or combinations of psychological treatments. No studies compared psychological interventions with no treatment or treatment as usual control conditions. The studies included a diverse range of participants (e.g. veterans, prisoners, community adults and adolescents). All studies were at high risk of performance bias, other main sources were selection, outcome detection and attrition bias. Due to heterogeneity between studies only two meta-analyses were conducted. The first meta-analysis focused on two studies (296 participants) comparing ICBT to TSF. Very low-quality evidence revealed that while the TSF group had lower depression scores than the ICBT group at post-treatment (mean difference (MD) 4.05, 95% confidence interval (CI) 1.43 to 6.66; 212 participants), there was no difference between groups in depression symptoms (MD 1.53, 95% CI -1.73 to 4.79; 181 participants) at six- to 12-month follow-up. At post-treatment there was no difference between groups in proportion of days abstinent (MD -2.84, 95% CI -8.04 to 2.35; 220 participants), however, the ICBT group had a greater proportion of days abstinent than the TSF group at the six- to 12-month follow-up (MD 10.76, 95% CI 3.10 to 18.42; 189 participants). There were no differences between the groups in treatment attendance (MD -1.27, 95% CI -6.10 to 3.56; 270 participants) or treatment retention (RR 0.95, 95% CI 0.72 to 1.25; 296 participants). The second meta-analysis was conducted with two studies (64 participants) comparing IPT-D with other treatment (Brief Supportive Psychotherapy/Psychoeducation). Very low-quality evidence indicated IPT-D resulted in significantly lower depressive symptoms at post-treatment (MD -0.54, 95% CI -1.04 to -0.04; 64 participants), but this effect was not maintained at three-month follow-up (MD 3.80, 95% CI -3.83 to 11.43) in the one study reporting follow-up outcomes (38 participants; IPT-D versus Psychoeducation). Substance use was examined separately in each study, due to heterogeneity in outcomes. Both studies found very low-quality evidence of no significant differences in substance use outcomes at post-treatment (percentage of days abstinent, IPD versus Brief Supportive Psychotherapy; MD -2.70, 95% CI -28.74 to 23.34; 26 participants) or at three-month follow-up (relative risk of relapse, IPT-D versus Psychoeducation; RR 0.67, 95% CI 0.30 to 1.50; 38 participants). There was also very low-quality evidence for no significant differences between groups in treatment retention (RR 1.00, 95% CI 0.81 to 1.23; 64 participants). No adverse events were reported in any study.

AUTHORS' CONCLUSIONS

The conclusions of this review are limited due to the low number and very poor quality of included studies. No conclusions can be made about the efficacy of psychological interventions (delivered alone or in combination with pharmacotherapy) for the treatment of comorbid depression and substance use disorders, as they are yet to be compared with no treatment or treatment as usual in this population. In terms of differences between psychotherapies, although some significant effects were found, the effects were too inconsistent and small, and the evidence of too poor quality, to be of relevance to practice.

Use of Prescribed Psychotropic Medications in an Opioid Substitution Therapy Cohort

Objective: Comorbid mental illness is extremely common in individuals receiving opioid substitution therapy. The use of common psychiatric medications is complex in this cohort with increased risks of drug-drug interaction, overdose, and diversion or abuse of prescribed medication. We have therefore investigated rates of co-prescribing and psychiatric comorbidity in a cohort of individuals receiving therapeutic methadone or buprenorphine. Methods: Comprehensive electronic medical records were accessed for a cohort of individuals (n = 698) receiving opioid substitution therapy at a single center in London, United Kingdom. The following was collected for each individual: demographic data, current prescribed medications (including opioid substitution therapy agents), duration of prescription, indication for each prescription, and psychiatric diagnoses. Results: A total of 610 individuals were included in the final analysis. High rates of psychotropic co-prescribing were observed, with 36.7% of individuals receiving a psychotropic medication in addition to their opioid substitution drug, including 35.4% receiving an antidepressant, 9.2% an antipsychotic, 8.6% a benzodiazepine, and 4.5% a gabapentinoid, rates that are far in excess of the local population prescription frequency; 75.5% of antipsychotic prescriptions and 47.7% of benzodiazepine prescriptions were for an unlicensed indication. Conclusions: This highlights the need for evidence-based treatment of comorbid mental illness for individuals receiving opioid substitution therapy.

Efficacy of Acupuncture for Treating Opioid Use Disorder in Adults: A Systematic Review and Meta-Analysis

OBJECTIVES

To assess the efficacy of acupuncture in treating opioid use disorder (OUD).

DESIGN

Systematic review and meta-analysis.

METHODS

PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, ProQuest Dissertation and Theses, Allied and Complementary Medicine Database (AMED), Clinicaltrials.gov, and who.int/trialsearch were searched from inception to 23 December 2017. The methodological quality of selected studies and the quality of evidence for outcomes were assessed, respectively, by the Cochrane risk of bias assessment tool and the GRADE approach. Statistical analyses were conducted by RevMan 5.3.

RESULTS

A total of nine studies involving 1063 participants fulfilled the inclusion criteria. The results showed that acupuncture could be more beneficial than no treatment/sham acupuncture in terms of changes in craving for opioid (MD -2.18, 95% CI -3.10 to -1.26), insomnia (MD 2.31, 95% CI 1.97 to 2.65), and depression (SMD -1.50, 95% CI -1.85 to -1.15). In addition, these findings showed that, compared to sham electroacupuncture (EA), EA had differences in alleviating symptoms of craving (SMD -0.50, 95% CI -0.94 to -0.05) and depression (SMD -1.07, 95% CI -1.88 to -0.25) and compared to sham transcutaneous acupoint electrical stimulation (TEAS), TEAS had differences in alleviating symptoms of insomnia (MD 2.31, 95% CI 1.97 to 2.65) and anxiety (MD -1.26, 95% CI -1.60 to -0.92) compared to no treatment/sham TEAS.

CONCLUSIONS

Acupuncture could be effective in treating OUD. Moreover, EA could effectively alleviate symptoms of craving for opioid and depression, and TEAS could be beneficial in improving symptoms of insomnia and anxiety. Nevertheless, the conclusions were limited due to the low-quality and small number of included studies. PROSPERO registration number is CRD42018085063.

Incidence and predictors of mental health disorder diagnoses among people who inject drugs in a Canadian setting

INTRODUCTION AND AIMS

Limited attention has been given to the predictors of mental health diagnoses among people who inject drugs (PWID) in community settings. Therefore, we sought to longitudinally examine the prevalence, incidence and predictors of mental disorder diagnosis among a community-recruited cohort of PWID.

DESIGN AND METHODS

Data were derived from two prospective cohort studies of PWID (VIDUS and ACCESS) in Vancouver, Canada between December 2005 and May 2015. We used multivariable extended Cox regression to identify factors independently associated with self-reported mental disorder diagnosis during follow-up among those without a history of such diagnoses at baseline.

RESULTS

Among the 923 participants who did not report a mental disorder at baseline, 206 (22.3%) reported a first diagnosis of a mental disorder during follow-up for an incidence density of 4.29 [95% confidence interval (CI) 3.72-4.91] per 100 person-years. In the multivariable analysis, female sex [adjusted hazards ratio (AHR) = 1.74, 95% CI 1.29-2.33], experiencing non-fatal overdose (AHR = 2.33, 95% CI 1.38-3.94), accessing any drug or alcohol treatment (AHR = 1.68, 95% CI 1.24-2.27), accessing any community health or social services (AHR = 1.53, 95% CI 1.02-2.28) and experiencing violence (AHR = 1.60, 95% CI 1.12-2.29) were independently associated with a mental disorder diagnosis at follow-up.

DISCUSSION AND CONCLUSIONS

We observed a high prevalence and incidence of mental disorders among our community-recruited sample of PWID. The validity and implication of these diagnoses for key substance use and public health outcomes are an urgent priority.

Buprenorphine-naloxone treatment responses differ between young adults with heroin and prescription opioid use disorders

BACKGROUND AND OBJECTIVES

Opioid use disorder among young adults is rising sharply with an increase in morbidity and mortality. This study examined differences in treatment response to a fixed dose of buprenorphine-naloxone between heroin (HU) and prescriptions opioids (POU) users.

METHODS

Eighty opioid dependent young adults (M = 22 years) were treated with buprenorphine-naloxone 16-4 mg/day for 8 weeks. Differences between HU (N = 17) and POU (N = 63) on changes in weekly opioid use, opioid craving, withdrawal, and depression symptoms were analyzed with mixed-effects regression models.

RESULTS

The HU had an overall mean proportion of weekly opioid use of .32 (SD = .14) compared to POU's weekly mean of .24 (SD = .15) showing a significant main effect (Z = 2.21, p = .02). Depressive symptoms (CES-D scores) were elevated at baseline for both groups (HU: M = 23.1, SD = 11.9; PO: M = 22.2, SD = 9.4), but only POU improved significantly to a score of 9.88 (SD = 7.4) compared to HU's score of 18.58 (SD = 10.3) at week 8 (Z = 2.24, p = .02). There were no significant differences in treatment retention, craving, or withdrawal symptoms.

DISCUSSION AND CONCLUSIONS

Treatment response to 16-4 mg/day of buprenorphine-naloxone was significantly diminished for heroin users relative to opioid prescription users in weekly opioid use. Heroin users also had persistent depressive symptoms suggesting the need for close monitoring.

SCIENTIFIC SIGNIFICANCE

These data suggest that young heroin users might require higher doses of buprenorphine. (Am J Addict 2017;26:838-844).