Explaining the effectiveness of heroin-assisted treatment on crime reductions

Who receives heroin-assisted treatment? A comparison of patients receiving opioid maintenance treatment in Denmark

BACKGROUND

Since 2010, heroin-assisted treatment (HAT) has been one of the treatment options available to people with opioid use disorder (OUD) in Denmark. This study aimed to characterize HAT patients at treatment start and compare their individual characteristics to those of patients entering traditional opioid maintenance treatment (OMT) with methadone or buprenorphine during the same period.

METHODS

Patients who initiated HAT or OMT with methadone or buprenorphine in Denmark from 2010 to 2018 were included (n=6798). Multiple national registers were linked to compare treatment groups in terms of socio-demographic variables, previous OUD treatment episodes, hospital-based care, and criminal conviction history.

RESULTS

Nearly all HAT patients had a history of methadone treatment (91%) and half had residential treatment experience (48%). In the year previous to admission, HAT patients recorded the highest percentages of non-fatal overdoses (12%) and chronic hepatitis C diagnoses (16%), and the lowest percentages of psychiatric disorders (11%) compared to traditional OMT patients. Criminal convictions were also common: 39% of the HAT group had committed a property crime and 18% a drug-related crime the year before HAT entry. During the study period, an overall reduction in OMT enrollments for each year was recorded. The HAT proportion to the total remained fairly stable (4%-10%), while the buprenorphine proportion increased.

CONCLUSIONS

In Denmark, OMT patients exhibited numerous vulnerabilities at treatment start, and among the patient groups, HAT patients were the most burdened. HAT seems to reach the target group and adhere to formulated eligibility criteria.

Heroin assisted treatment for key health outcomes in people with chronic heroin addictions: A context-focused systematic review

BACKGROUND AND AIMS

Randomised controlled trials in Europe and Canada have shown that supervised heroin assisted treatment (HAT) is an effective treatment option for people with long-term heroin addictions for whom the standard opioid substitution treatments (OST) have not been effective. This review aims to evaluate the effectiveness of supervised HAT and analyse the significance of context and implementation in the design of successful HAT programmes.

METHODS

PubMed, CENTRAL, Embase, and Web of Science were searched to identify randomised controlled trials (RCT) and systematic reviews evaluating supervised HAT compared to any other OST. Studies were eligible for inclusion if they were published in English, evaluated a supervised form of HAT, and included illegal drug use and/or health as a primary outcome measure. There were no restrictions on publication date. The following outcomes of the included studies were analysed using narrative synthesis and meta-analysis where possible: retention, street drug use, health, and social functioning.

RESULTS

Nine randomised controlled trials spanning eight studies (n = 2331) and three systematic reviews met the inclusion criteria. Seven of the eight studies compared HAT to methadone maintenance treatment (MMT). One study compared HAT to injectable hydromorphone in a double-blind non-inferiority trial. Meta-analysis was performed on pooled results of retention across all included studies and found that HAT has a statistically significant effect on retention [Z = 7.65 (P > 0.0001)]. Five of the eight included studies found that supervised HAT reduces participants' use of illegal drugs more significantly than MMT. Evidence of improved health in participants receiving supervised HAT compared to other OSTs was inconsistent; positive effects were observed in three of the included studies (n = 1626).

CONCLUSION

When compared to methadone maintenance treatment (MMT), heroin assisted treatment (HAT) more consistently retains people with heroin addictions in treatment and reduces their consumption of illicit drugs.

TRIAL REGISTRATION

PROSPERO registration: CRD42022341306.

Exploring why patients in heroin-assisted treatment are getting incarcerated-a qualitative study

BACKGROUND

Heroin-assisted treatment has proven effective in reducing criminal offenses in opioid dependent individuals. Few studies attempted to explain the observed crime reduction and the reasons why these patients keep offending and getting incarcerated have to date not been explored.

METHODS

Patients with a history of incarcerations during the time of participating in heroin-assisted treatment (n = 22) were invited to a semi-structured, narrative interview. Findings were evaluated with Mayring's qualitative content analysis framework. Additionally, the Montreal Cognitive Assessment test and the multiple-choice vocabulary intelligence test used to assess cognitive impairment and premorbid intelligence levels.

RESULTS

Three main categories emerged in patients' narratives on their incarcerations: cocaine use, impaired functioning, and financial constraints. Lifetime prevalence of cocaine use disorder was 95.5% and their cocaine use often led to patients getting incarcerated. Impaired functioning mainly constituted the inability to receive and open mail. Financial constraints led to incarcerations in lieu of payment in 16 participants (72.7%). Categories overlapped notably and often occurred in close temporal proximity. A fourth category on the likelihood of getting incarcerated again in the future was inhomogeneous and ranged from the strong conviction to complete rejection of the scenario. Average premorbid intelligence levels were found, whereas the cognitive assessment suggested severe cognitive impairment in our sample.

CONCLUSION

Participants mainly reported to have committed minor offenses and not being able to pay for resulting fines. The resulting prison sentences are an unconvincing practice from a medical and economic perspective alike. Public expenditure and the interruptions of the continuum of care could be reduced by legislatively protecting these marginalised patients.

Does heroin-assisted treatment reduce crime? A review of randomized-controlled trials

BACKGROUND AND AIMS

Several randomized controlled trials (RCTs) conclude that heroin-assisted-treatment (HAT) has a larger benefit-cost ratio than oral methadone because HAT more reliably and substantially reduces participants' criminal activity. This review: (1) summarizes results from RCTs concerning the comparative effectiveness of HAT for reducing criminal activity and (2) examines the role of different mechanisms for explaining changes in crime.

DESIGN

Systematic search of five databases for RCTs evaluating comparative effectiveness of HAT on participant crime outcomes and potential mediators of crime. Narrative synthesis with tabular comparisons of outcomes extracted across RCTs.

SETTING

Europe and Canada.

PARTICIPANTS

Twenty studies, spanning 10 RCTs with 2427 participants, met inclusion criteria.

INTERVENTIONS

HAT compared to other treatments for opioid use disorder, primarily oral methadone.

MEASUREMENTS

The primary outcome was criminal activity. Mediator outcomes included illicit heroin use, drug expenditures, employment and earnings and social functioning.

FINDINGS

All trials found significantly reduced criminal activity among HAT participants, and four found significantly larger reductions for HAT compared to control condition [median odds ratios (ORs) = 0.45]. Reductions in crime are concentrated in drug-related and property offenses (ORs range from 0.14 to 0.90 and from 0.12 to 1.89, respectively). Comparative efficacy of HAT for reducing illicit heroin use probably explains reductions in drug possession offenses, but does not show consistent correlation with drug dealing or property offenses. While three trials showed reductions in drug expenditures as possibly driving crime reductions, others did not report expenditures. There is little evidence that treatment effects on economic and social functioning outcomes explain within-trial changes in criminal activity.

CONCLUSIONS

Existing literature suggests that heroin-assisted treatment reduces criminal activity, but trials varied in whether these effects exceeded those from oral methadone treatment. Inconsistency in outcome measures across trials complicates understanding drivers of heterogeneity. More detailed information on legal and illegal income, drug expenditures and social interactions could improve our understanding of the causal mechanisms underlying the effect of heroin-assisted-treatment on crime.

Injectable opioid agonist treatment: An evolutionary concept analysis

Canada is currently in the midst of an overdose crisis. With new and innovative approaches desperately needed, injectable opioid agonist treatment (iOAT) should be considered as an integral treatment option to prevent even more fatalities. These programs provide injectable diacetylmorphine or hydromorphone to clients with severe opioid use disorders. Currently, they remain an under-executed and under-studied treatment modality. To better understand why this may be, we performed an evolutionary concept analysis as described by Rodgers. The attributes, antecedents, consequences, and surrogate terms of iOAT were unpacked and explored. Further, four themes were identified within the literature: (1) physical and mental health, (2) illicit drug use, (3) criminal behavior, and (4) ethical considerations. Recommendations surrounding the need for additional studies that focus on the perspectives of people who use opioids (PWUO), the necessity of nursing advocacy in iOAT, and the consideration of a changing illicit drug supply were explored. Further, theoretical analysis coupled with direct input from PWUO was discussed as a necessity to move forward with iOAT.

'I could have went down a different path': Talking to people who used drugs problematically and service providers about Irish drug policy alternatives

BACKGROUND

People who use drugs problematically are consistently left out of consultations and deliberation on drug policy. This article explores how people who formerly used drugs problematically and service providers view Ireland's current drug policy and if alternative policies could be successful in an Irish context.

METHODS

Semi-structured interviews were conducted with eight people who used drugs problematically and six practitioners working with people who use drugs in Cork city, Ireland. All people who used drugs problematically had at least one year of abstinence and had been criminalised because of their drug use, all but one had served at least one custodial sentence. Participants were asked their opinions on safe injecting facilities, heroin assisted treatment, decriminalisation of drugs for personal use, depenalisation of cannabis and, the relationships between economic deprivation and problematic drug use.

RESULTS

Respondents stressed that, in Cork city, problematic drug use is closely linked with economic deprivation and social exclusion. There was a near consensus that criminalisation and penalisation do not deter consumption and produce unintended consequences. All participants supported safe injecting facilities and the decriminalisation of drugs for personal use. Participants were less certain about the utility of heroin assisted treatment and depenalisation of cannabis. Many discussions drifted away from alternatives policies towards the need for improved treatment provision.

CONCLUSION

Several participants were clear that none of the alternative policies discussed are silver bullets. Participates felt that, while they could reduce the harms caused by drugs and drug policies, the government's longer-term objectives should be increased treatment provision and, reduced social exclusion and economic deprivation.

Prescribe to Prevent: Overdose Prevention and Naloxone Rescue Kits for Prescribers and Pharmacists

In March of 2015, the United States Department of Health and Human Services identified 3 priority areas to reduce opioid use disorders and overdose, which are as follows: opioid-prescribing practices; expanded use and distribution of naloxone; and expansion of medication-assisted treatment. In this narrative review of overdose prevention and the role of prescribers and pharmacists in distributing naloxone, we address these priority areas and present a clinical scenario within the review involving a pharmacist, a patient with chronic pain and anxiety, and a primary care physician. We also discuss current laws related to naloxone prescribing and dispensing. This review was adapted from the Prescribe to Prevent online continuing medical education module created for prescribers and pharmacists (http://www.opioidprescribing.com/naloxone_module_1-landing).

Criminal Charges Prior to and After Enrollment in Opioid Agonist Treatment: A Comparison of Methadone Maintenance and Office-based Buprenorphine

BACKGROUND

Entry into methadone maintenance is associated with a reduction in criminal activity; less is known about the effects of office-based buprenorphine.

OBJECTIVE

To compare criminal charges before and after enrollment in methadone maintenance or office-based buprenorphine.

METHODS

Subjects were opioid-dependent adults who initiated either methadone maintenance (n = 252) or office-based buprenorphine (n = 252) between 2003 and 2007. Medical records were reviewed to gather demographic data and a state-maintained web-based database to collect data on criminal charges. Overall charges and drug charges in the 2 years prior to and after treatment enrollment were compared. Multivariable analysis was used to examine risk factors for charges after treatment enrollment.

RESULTS

In the 2 years after enrolling in treatment, subjects receiving methadone had a significant decline in the proportion of subjects with any charges (49.6% vs. 32.5%, p < .001) or drug charges (25.0% vs. 17.5%, p = .015), as well as the mean number of cases (0.97 vs. 0.63, p = .002) and drug cases (0.38 vs. 0.23, p = .008), while those who initiated buprenorphine did not have significant changes in any of these measures. On multivariable analysis, the strongest predictor of criminal charges in the 2 years after treatment enrollment was prior charges (adjusted odds ratio 3.35, 95% confidence interval, 2.24-5.01).

CONCLUSIONS

Enrollment in office-based buprenorphine treatment did not appear to have the same beneficial effect on subsequent criminal charges as methadone maintenance. If this observation is replicated in other settings, it may have implications for matching individuals to these treatment options.

Pharmacological interventions for drug-using offenders

BACKGROUND

The review represents one in a family of four reviews focusing on a range of different interventions for drug-using offenders. This specific review considers pharmacological interventions aimed at reducing drug use or criminal activity, or both, for illicit drug-using offenders.

OBJECTIVES

To assess the effectiveness of pharmacological interventions for drug-using offenders in reducing criminal activity or drug use, or both.

SEARCH METHODS

We searched Fourteen electronic bibliographic databases up to May 2014 and five additional Web resources (between 2004 and November 2011). We contacted experts in the field for further information.

SELECTION CRITERIA

We included randomised controlled trials assessing the efficacy of any pharmacological intervention a component of which is designed to reduce, eliminate or prevent relapse of drug use or criminal activity, or both, in drug-using offenders. We also report data on the cost and cost-effectiveness of interventions.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane.

MAIN RESULTS

Fourteen trials with 2647 participants met the inclusion criteria. The interventions included in this review report on agonistic pharmacological interventions (buprenorphine, methadone and naltrexone) compared to no intervention, other non-pharmacological treatments (e.g. counselling) and other pharmacological drugs. The methodological trial quality was poorly described, and most studies were rated as 'unclear' by the reviewers. The biggest threats to risk of bias were generated through blinding (performance and detection bias) and incomplete outcome data (attrition bias). Studies could not be combined all together because the comparisons were too different. Only subgroup analysis for type of pharmacological treatment were done. When compared to non-pharmacological, we found low quality evidence that agonist treatments are not effective in reducing drug use or criminal activity, objective results (biological) (two studies, 237 participants (RR 0.72 (95% CI 0.51 to 1.00); subjective (self-report), (three studies, 317 participants (RR 0.61 95% CI 0.31 to 1.18); self-report drug use (three studies, 510 participants (SMD: -0.62 (95% CI -0.85 to -0.39). We found low quality of evidence that antagonist treatment was not effective in reducing drug use (one study, 63 participants (RR 0.69, 95% CI 0.28 to 1.70) but we found moderate quality of evidence that they significantly reduced criminal activity (two studies, 114 participants, (RR 0.40, 95% CI 0.21 to 0.74).Findings on the effects of individual pharmacological interventions on drug use and criminal activity showed mixed results. In the comparison of methadone to buprenorphine, diamorphine and naltrexone, no significant differences were displayed for either treatment for self report dichotomous drug use (two studies, 370 participants (RR 1.04, 95% CI 0.69 to 1.55), continuous measures of drug use (one study, 81 participants, (mean difference (MD) 0.70, 95% CI -5.33 to 6.73); or criminal activity (one study, 116 participants, (RR 1.25, 95% CI 0.83 to 1.88) between methadone and buprenorphine. Similar results were found for comparisons with diamorphine with no significant differences between the drugs for self report dichotomous drug use for arrest (one study, 825 participants, (RR 1.25, 95% CI 1.03 to 1.51) or naltrexone for dichotomous measures of reincarceration (one study, 44 participants, (RR 1.10, 95% CI 0.37 to 3.26), and continuous outcome measure of crime, (MD -0.50, 95% CI -8.04 to 7.04) or self report drug use (MD 4.60, 95% CI -3.54 to 12.74).

AUTHORS' CONCLUSIONS

When compared to non-pharmacological treatment, agonist treatments did not seem effective in reducing drug use or criminal activity. Antagonist treatments were not effective in reducing drug use but significantly reduced criminal activity. When comparing the drugs to one another we found no significant differences between the drug comparisons (methadone versus buprenorphine, diamorphine and naltrexone) on any of the outcome measures. Caution should be taken when interpreting these findings, as the conclusions are based on a small number of trials, and generalisation of these study findings should be limited mainly to male adult offenders. Additionally, many studies were rated at high risk of bias.

Interventions for drug-using offenders with co-occurring mental illness

BACKGROUND

This is an updated version of an original Cochrane review published in Issue 3 2006 (Perry 2006). The review represents one from a family of four reviews focusing on interventions for drug-using offenders. This specific review considers interventions aimed at reducing drug use or criminal activity, or both for drug-using offenders with co-occurring mental illness.

OBJECTIVES

To assess the effectiveness of interventions for drug-using offenders with co-occurring mental illness in reducing criminal activity or drug use, or both.

SEARCH METHODS

We searched 14 electronic bibliographic databases up to May 2014 and 5 Internet resources (searched between 2004 and 11 November 2009). We contacted experts in the field for further information.

SELECTION CRITERIA

We included randomised controlled trials designed to reduce, eliminate, or prevent relapse of drug use and criminal activity, or both in drug-using offenders with co-occurring mental illness. 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

Eight trials with 2058 participants met the inclusion criteria. The methodological quality of the trials was generally difficult to rate due to a lack of clear reporting. On most 'Risk of bias' items, we rated the majority of studies as unclear. Overall, we could not statistically combine the results due to the heterogenous nature of the different study interventions and comparison groups. A narrative summary of the findings identified that the interventions reported limited success with reducing self report drug use, but did have some impact on re-incarceration rates, but not re-arrest. In the single comparisons, we found moderate-quality evidence that therapeutic communities determine a reduction in re-incarceration but reported less success for outcomes of re-arrest, moderate quality of evidence and self report drug use. Three single studies evaluating case management via a mental health drug court (very low quality of evidence), motivational interviewing and cognitive skills (low and very low quality of evidence) and interpersonal psychotherapy (very low quality of evidence) did not report significant reductions in criminal activity and self report drug use respectively. Quality of evidence for these three types of interventions was low to very low. The trials reported some cost information, but it was not sufficient to be able to evaluate the cost-effectiveness of the interventions.

AUTHORS' CONCLUSIONS

Two of the five trials showed some promising results for the use of therapeutic communities and aftercare, but only in relation to reducing subsequent re-incarceration. Overall, the studies showed a high degree of variation, warranting a degree of caution in the interpretation of the magnitude of effect and direction of benefit for treatment outcomes. More evaluations are required to assess the effectiveness of interventions for drug-using offenders with co-occurring mental health problems.

Interventions for female drug-using offenders

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.

Predictors of non-use of illicit heroin in opioid injection maintenance treatment of long-term heroin dependence

AIMS

To investigate baseline and concurrent predictors of non-use of illicit heroin among participants randomized to injectable opioids in the North American Opiate Medication Initiative (NAOMI) clinical trial.

METHODS

NAOMI was an open-label randomized controlled trial comparing the effectiveness of injectable diacetylmorphine and hydromorphone for long-term opioid-dependency. Outcomes were assessed at baseline and during treatment (3, 6, 9, 12months). Days of non-use of illicit heroin in the prior month at each follow-up visit were divided into three categories: Non-use; Low use (1 to 7days) and High use (8days or more). Tested covariates were: Sociodemographics, Health, Treatment, Drug use and illegal activities. Mixed-effect proportional odds models with random intercept for longitudinal ordinal outcomes were used to assess the predictors of the non-use of illicit heroin.

RESULTS

139 participants were included in the present analysis. At each follow-up visit, those with non-use of illicit heroin represented 47.5% to 54.0% of the sample. Fewer days of cocaine use (p=0.074), fewer days engaged in illegal activities at baseline (p<0.01) and at each visit (p<0.01), less money spent on drugs (p<0.001), days with injection opioid or oral methadone treatment (p<0.001) and total mg of injectable opioids taken (p<0.001), independently predicted lower use of illicit heroin.

CONCLUSIONS

The independent effect of several concurrent factors besides the injection of opioid dose suggests benefits from the clinic that go beyond the provision of the medication alone. Thus, this supervised model of care presents an opportunity to maximize the beneficial impact of medical and psychosocial components of the treatment on improving outcomes associated with non-use of illicit heroin.

Efficacy of Heroin-assisted Treatment In Belgium: A Randomised Controlled Trial

BACKGROUND/AIMS

Heroin-assisted treatment (HAT) can improve the condition of heroin addicts still using street heroin after a methadone treatment. In Belgium, a new trial compared the efficacy of a HAT to existing methadone maintenance treatment.

METHODS

In this randomised controlled trial, HAT was limited to 12 months. Participants were assessed every 3 months. They were responders if they showed improvement on the level of street heroin use, health or criminal involvement.

RESULTS

74 participants were randomised in the trial. The experimental group (n = 36) counted 30% of responders more than the control group (n = 38) at each assessment point (p < 0.05), except at 12 months where the difference (11%) was no longer significant (p = 0.35). Still, after 12 months, participants in the experimental group reported significantly greater improvements (p < 0.05) than the control group on the level of street heroin use and on the level of physical and mental health. Both groups reported significantly less criminal acts after 12 months (p < 0.001), but with no significant difference between the groups.

CONCLUSIONS

This trial confirms the short-term efficacy of HAT for severe heroin addicts, who already failed methadone treatment.

Feasibility of applying the life history calendar in a population of chronic opioid users to identify patterns of drug use and addiction treatment

Uncovering patterns of drug use and treatment access is essential to improving treatment for opioid dependence. The life history calendar (LHC) could be a valuable instrument for capturing time-sensitive data on lifetime patterns of drug use and addiction treatment. This study describes the methodology applied when collecting data using the LHC in a sample of individuals with long-term opioid dependence and aims to identify specific factors that impact the feasibility of administering the LHC interview. In this study, the LHC allowed important events such as births, intimate relationships, housing, or incarcerations to become reference points for recalling details surrounding drug use and treatment access. The paper concludes that the administration of the LHC was a resource-intensive process and required special attention to interviewer training and experience with the study population. These factors should be considered and integrated into study plans by researchers using the LHC in addiction research.

'Miracle cure' or 'liquid handcuffs': reporting on naltrexone and methadone in the Australian print media

INTRODUCTION AND AIMS

The news media is an important source of information regarding new developments in medicine and public health interventions. Previous research has indicated that in many cases, reporting on new treatments can be inaccurate or sensationalist. This paper presents analysis of Australian print media reporting on two treatment options for heroin dependence (naltrexone and methadone). The aim of this study was to quantitatively compare the volume and content of Australian print media reporting on these two treatments, one of which had a long history of use in Australia, and the other which was comparatively newer.

DESIGN AND METHODS

The study constituted a quantitative content analysis of a sample of 859 Australian newspaper articles, published over a 10-year period (1997-2007). Each article paragraph was coded for positive outcomes/benefits of treatment, as well as negative outcomes associated with treatment.

RESULTS

The analysis revealed that during this period, the Australian print media was significantly more likely to report the potential positive outcomes of naltrexone treatment, compared with the negative outcomes. In contrast, reporting on methadone focused more on the negative outcomes and side effects.

DISCUSSION AND CONCLUSIONS

The relative frequency by which the benefits of naltrexone were mentioned in this sample of news content is somewhat at odds with the extant efficacy and effectiveness research evidence. The findings suggest that reporting on these treatments in the Australian print media has not been balanced. This type of reporting has potential implications for public attitudes, as well as policy decisions.

Pattern of QTc prolongation in Methadone Maintenance Therapy (MMT) subjects receiving different methadone dosages: A prospective cohort study

Objectives: This study aimed to compare the QTc interval between low and high dose methadone groups and evaluate the pattern of QTc variation.

Methods: This is a prospective cohort study conducted from December 2010 till August 2011 at Malaysian University of Science’s Hospital. Forty six subjects, grouped in high dose (>80mg) and low dose (<80mg) oral methadone, were followed-up at 4-weekly for QTc measurements. Relevant demographic and biochemical profiles were taken at intervals with concurrent QTc measurements.

Results: No significant QTc differences between methadone dosage groups were found at Week 0 (434ms vs 444ms, p = 0.166) and week 8 (446.5ms vs 459ms, p = 0.076), but not at week 4(435ms vs 450ms, p = 0.029). However, there were significant associations between the groups with QT_c prolongation at week 0 and 4 (OR 4.29(95% CI 1.01, 18.72) p=0.044 and OR 5.18 (95% CI 1.34, 20.06) p =0.013, respectively) but not at week 8 (OR 2.44 (95% CI 0.74, 8.01) p=0.139). On multivariate analysis, dose group was the sole significant factor for QT_c prolongation for week 0 and 4 (p values 0.047 and 0.017, respectively), but not at week 8.

Conclusion: High-dose methadone group is more likely to develop prolonged QTc than low-dose group. However, such effects were inconsistent and occurred even during chronic methadone therapy, mandating judicious QTc and serum methadone monitoring.

Criminal charges prior to and after initiation of office-based buprenorphine treatment

Background

There is little data on the impact of office-based buprenorphine therapy on criminal activity. The goal of this study was to determine the impact of primary care clinic-based buprenorphine maintenance therapy on rates of criminal charges and the factors associated with criminal charges in the 2 years after initiation of treatment.

Methods

We collected demographic and outcome data on 252 patients who were given at least one prescription for buprenorphine. We searched a public database of criminal charges and recorded criminal charges prior to and after enrollment. We compared the total number of criminal cases and drug cases 2 years before versus 2 years after initiation of treatment.

Results

There was at least one criminal charge made against 38% of the subjects in the 2 years after initiation of treatment; these subjects were more likely to have used heroin, to have injected drugs, to have had any prior criminal charges, and recent criminal charges. There was no significant difference in the number of subjects with any criminal charge or a drug charge before and after initiation of treatment. Likewise, the mean number of all cases and drug cases was not significantly different between the two periods. However, among those who were opioid-negative for 6 or more months in the first year of treatment, there was a significant decline in criminal cases. On multivariable analysis, having recent criminal charges was significantly associated with criminal charges after initiation of treatment (adjusted odds ratio 3.92); subjects who were on opioid maintenance treatment prior to enrollment were significantly less likely to have subsequent criminal charges (adjusted odds ratio 0.52).

Conclusions

Among subjects with prior criminal charges, initiation of office-based buprenorphine treatment did not appear to have a significant impact on subsequent criminal charges.

Heroin maintenance for chronic heroin-dependent individuals

BACKGROUND

Several types of medications have been used for stabilizing heroin users: Methadone, Buprenorphine and levo-alpha-acetyl-methadol (LAAM.) The present review focuses on the prescription of heroin to heroin-dependent individuals.

OBJECTIVES

To compare heroin maintenance to methadone or other substitution treatments for opioid dependence regarding: efficacy and acceptability, retaining patients in treatment, reducing the use of illicit substances, and improving health and social functioning.

SEARCH METHODS

A review of the Cochrane Central Register of Trials (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to november 2009), EMBASE (1980 to 2005) and CINAHL until 2005 (on OVID) was conducted. Personal communications with researchers in the field of heroin prescription identified ongoing trials.

SELECTION CRITERIA

Randomised controlled trials of heroin maintenance treatment (alone or combined with methadone) compared with any other pharmacological treatment for heroin-dependent individuals.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

Eight studies involving 2007 patients met the inclusion criteria. Five studies compared supervised injected heroin plus flexible dosages of methadone treatment to oral methadone only and showed that heroin helps patients to remain in treatment (valid data from 4 studies, N=1388 Risk Ratio 1.44 (95%CI 1.19-1.75) heterogeneity P=0.03), and to reduce use of illicit drugs. Maintenance with supervised injected heroin has a not statistically significant protective effect on mortality (4 studies, N=1477 Risk Ratio 0.65 (95% CI 0.25-1.69) heterogeneity P=0.89), but it exposes at a greater risk of adverse events related to study medication (3 studies N=373 Risk Ratio 13.50 (95% CI 2.55-71.53) heterogeneity P=0.52). Results on criminal activity and incarceration were not possible to be pooled but where the outcome were measured results of single studies do provide evidence that heroin provision can reduce criminal activity and incarceration/imprisonment. Social functioning improved in all the intervention groups with heroin groups having slightly better results. If all the studies comparing heroin provision in any conditions vs any other treatment are pooled the direction of effect remain in favour of heroin.

AUTHORS' CONCLUSIONS

The available evidence suggests an added value of heroin prescribed alongside flexible doses of methadone for long-term, treatment refractory, opioid users, to reach a decrease in the use of illicit substances, involvement in criminal activity and incarceration, a possible reduction in mortaliity; and an increase in retention in treatment. Due to the higher rate of serious adverse events, heroin prescription should remain a treatment for people who are currently or have in the past failed maintenance treatment, and it should be provided in clinical settings where proper follow-up is ensured.

Sleeping problems among Chinese heroin-dependent individuals

BACKGROUND

Heroin abuse is a major public health problem with high morbidity and mortality. Treatment-seeking heroin-dependent subjects frequently report sleep-related problems that contribute to high relapse rates. Few studies have systematically studied the prevalence of sleep disorders among Chinese heroin-dependent subjects.

OBJECTIVES

This study aimed to explore the prevalence of sleep disorders with a battery of self-reported questionnaires in 140 heroin-dependent subjects in China.

METHODS

A self-report survey design was used to gather the data, using the Pittsburgh Sleep Quality Index (PSQI), Zung's Self-Rating Anxiety Scale (SAS), and Zung's Self-Rating Depression Scale (SDS). A total of 140 drug users participated in the survey.

RESULTS

PSQI results revealed that poor sleep quality (PSQI ≥ 8) was noted in 130 (96.30%) subjects. Those who displayed depressive symptoms, smoked and drank excessively, and had long-term histories of drug use had poorer sleep quality than those who did not. No correlation was found between anxiety, quantity of drugs, and sleeping disorders.

CONCLUSIONS

This study found that the majority of heroin-dependent patients reported poor sleep quality. Depression, smoking, drinking, and long-term drug use were associated with poor sleep quality in heroin-dependent individuals.

SCIENTIFIC SIGNIFICANCE

Despite the fact that this study collected data only using self-report measures, focused only on heroin-dependent patients, and did not include long-term follow-up study, given the potential link between poor sleep quality and relapse, factoring in this link is an important consideration as part of a comprehensive heroin-dependent treatment program.

Quality of life under maintenance treatment with heroin versus methadone in patients with opioid dependence

BACKGROUND

There is increasing evidence that health-related quality of life (HRQOL) is associated with a successful treatment and better outcome in opioid addiction. The aim of the present study was the longitudinal investigation of HRQOL in patients with severe opioid dependence, who were randomly assigned to four groups of medical and psychosocial treatment: heroin (diacetylmorphine) versus methadone and case management (CM) versus psychoeducation (PSE) respectively.

METHODS

HRQOL (MSQoL) and physical health (OTI) were investigated in 938 subjects, who participated in the German multi-centre study examining the effects of heroin-assisted treatment in patients with severe opioid dependence. Data for the present analysis were taken from baseline and 12-month follow up.

RESULTS

Under both forms of maintenance and psychosocial treatment HRQOL improved significantly during the observation period. HRQOL improvement under maintenance with heroin exceeded improvement under methadone, especially with regard to subjective physical health. HRQOL improvement was significantly associated with better expert-rated physical health. Further analyses showed significant better improvement of HRQOL in subjects treated with PSE compared with CM.

CONCLUSIONS

The advantage of heroin with regard to the improvement of HRQOL may be partially explained by a better improvement of physical health under maintenance with heroin compared with methadone, which highlights the importance of a comprehensive model of health care for patients with severe opioid dependence. Future studies need to investigate the benefits of PSE for patients in maintenance therapy.

Heroin maintenance for chronic heroin-dependent individuals

BACKGROUND

Several types of medications have been used for stabilizing heroin users: Methadone, Buprenorphine and levo-alpha-acetyl-methadol (LAAM.) The present review focuses on the prescription of heroin to heroin-dependent individuals.

OBJECTIVES

To compare heroin maintenance to methadone or other substitution treatments for opioid dependence regarding: efficacy and acceptability, retaining patients in treatment, reducing the use of illicit substances, and improving health and social functioning.

SEARCH STRATEGY

A review of the Cochrane Central Register of Trials (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to 2008), EMBASE (1980 to 2005) and CINAHL until 2005 (on OVID) was conducted. Personal communication with researchers in the field of heroin prescription identified other ongoing trials.

SELECTION CRITERIA

Randomised controlled trials of heroin maintenance treatment (alone or combined with methadone) were compared with any other pharmacological treatment for heroin-dependent individuals.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

Eight studies involving 2007 patients were included. Results show marginal significance in favour of heroin for remaining in treatment until the end of the study (8 studies, N= 2007, RR=1.23, 95%CI=0.96-1.57; heterogeneity P < 0.01). Adverse events are significantly more frequent in the heroin group. Heroin plus methadone prescription for maintenance treatment in adult chronic opioid users who failed previous methadone treatment attempts decreases the use of other illicit substances (3 Studies, N=1289, RR=0.63, 95%CI=0.49, 0.81, heterogeneity P=0.21), and reduces the risk of being incarcerated (2 studies, N=1103, RR=0.64, 95%CI=0.51-0.79, heterogeneity P=0.31). In addition, we also found a marginally significant protective effect of heroin prescription plus methadone for the use of street heroin (3 studies, N=1512, RR=0.70, 95%CI=0.49-1.00, heterogeneity P < 0.01) and for criminal activity (4 studies, N=1377, RR=0.80, 95%CI=0.61-1.04, heterogeneity P=0.31). There was not enough power to detect statistically significant results for the risk of death (5 studies, N=1817, RR=0.77, 95%CI=0.32-1.87, heterogeneity P=0.79).

AUTHORS' CONCLUSIONS

The available evidence suggests a small added value of heroin prescribed alongside flexible doses of methadone for long-term, treatment-refractory opioid users, considering a decrease in the use of street heroin and other illicit substances, and in the probability of being imprisoned; and an increase in retention in treatment. Due to the higher rate of serious adverse events, heroin prescription should remain a treatment of last resort for people who are currently or have in the past failed maintenance treatment.

Impact of one-year methadone maintenance treatment in heroin users in jiangsu province, china

CONTEXT

Although the effectiveness of methadone maintenance treatment (MMT) is well-established in many countries, it is a relatively new therapy for heroin users in China. Jiangsu Province, a relatively wealthy province, set up 4 MMT clinics in February 2006. No previous studies have evaluated the impact of MMT in a wealthy Chinese province.

OBJECTIVE

The aim of this study is to evaluate the impact of a 1-year MMT among heroin users in Jiangsu Province. We investigated the impact of the treatment by examining the following outcomes: 1) reduction of heroin use, 2) increase of appropriate sexual intercourse, 3) reduction of antisocial behavior, 4) increase of better social and family relationships, and 5) HIV prevalence among heroin users in MMT clinics.

DESIGN AND SETTING

Repeated cross-sectional surveys were conducted before and after heroin users in Jiangsu Province received at least 1-year of treatment in the MMT clinics. A questionnaire survey was implemented for those who agreed to participate from March to April 2006, before the initiation of MMT (N = 554). The second survey was from August to September 2007 and was administered to those who received MMT for more than 1 year (N = 804). One hundred and ninety-six patients who were investigated in both surveys were included in a longitudinal study to evaluate the factors attributable to behavior change.

RESULTS

MMT helped in reducing the percentage of heroin injection and also improved social and familial relationships. Antisocial behavior, including theft, prostitution, and dealing in heroin, decreased after 1-year treatment in the MMT clinics. However, the percentage of patients using condoms was not statistically significant. No case was found to be HIV-positive among those who received more than 1 year MMT. In the longitudinal study of 196 patients who participated in both surveys, no specific demographic variables were found to be associated with heroin use, anti-social behaviors after 1-year MMT.

CONCLUSIONS

MMT was thought to reduce heroin use, antisocial behaviors and HIV prevalence, and increased appropriate sexual intercourse behaviors and better social and family relationships among heroin users in a wealthy province in China, which was true regardless of gender, age, marital status, or working status.