Predictors of favorable outcome following naltrexone treatment

Predictive factors of long-term follow-up in treatment of Korean alcoholics with naltrexone or acamprosate

Medication is integral in treating alcohol use disorder. However, because of the small to medium effect size, much effort is being exerted to identify predicting factors for effective pharmacological treatment in alcohol abuse disorder. Rather than focusing on abstinence days, alcohol craving, or frequency of drinking, which has been the focus of previous studies. Recently, there have been several studies which focused on follow-up length as an indicator of pharmacological treatment effe ctiveness. The purpose of this study was to investigate the predicting factors of long-term follow-up in treating Korean alcoholics with naltrexone or acamprosate. A retrospective study was conducted. Medical records of all patients diagnosed from November 2008 to May 2017 with alcohol abuse or alcohol dependence at psychiatric clinics at PNUYH were reviewed. We examined total days of which naltrexone or acamprosate were prescribed, and investigated if there were predicting factors maintaining follow-up at least 180 days or more. With these data, logistic regression analysis was conducted. In naltrexone long group compared to naltrexone short group, factors of having medical comorbidities [odds ratio (OR) = 5.477, P = 0.012] showed higher OR. In acamprosate long group, factors of age (OR = 1.083, P = 0.030), and use of more than four psychotropic medications (OR = 7.107, P = 0.030), showed higher OR. In both medications, predicting factors were different from the other. Further study to investigate the reasons would provide us with a new insight.

Predictors for retention in treatment with a UK community-based naltrexone programme for opioid dependence

Aims and method

To evaluate the efficacy of naltrexone maintenance therapy in a community-based programme for opioid-dependent patients and to identify predictors for longer-term retention in treatment. A retrospective case-note study was conducted in 142 people dependent on opioids who had undergone detoxification and maintained adherence to naltrexone treatment for a minimum of 4 weeks. Social and clinical demographic factors during treatment were recorded using a standardised naltrexone monitoring scale. Efficacy was measured as retention in treatment, and potential predictors were examined using regression analysis.

Results

Although there was overall low retention of patients in treatment, 55.6% of the patients remained in treatment for 4–8 weeks, and 29.6% of the patients remained in treatment for 17 weeks or more. Enhanced long-term retention in treatment was associated with Asian or other minority ethnic status, employment, parental supervision of naltrexone administration, less boredom, short duration of addiction, younger age, low alcohol intake and no cannabis use in univariate analyses. Short duration of opioid dependence syndrome (3 years) and low alcohol intake (<10 units/week) were significant independent predictors for longer-term retention in treatment in subsequent multivariate analysis.

Clinical implications

Low alcohol intake and shorter duration of addiction were significant independent predictors for longer-term retention in treatment, but retention rates for naltrexone remain low overall. Additional psychosocial support may be needed to address these issues.

Research Note — Review of Corrections-Based Therapy for Opiate-Dependent Patients: Implications for Buprenorphine Treatment among Correctional Populations

Inmates with a history of opiate dependence represent a substantial proportion of the correctional population in the United States. Opiate use has negative consequences for both the inmate and society, including increased recidivism rates, increased infectious disease prevalence, avoidable emergency room use, decreased access to primary care services, and overdose. While there have been great successes in community-based treatment of opiate dependence, these successes have not yet been achieved in correctional settings. This paper reviews the pharmacological treatment options for opiate-dependent inmates, along with potential application for community-to-correctional approaches. The recent approval by the Food and Drug Administration (FDA) of physician-prescribed buprenorphine and the new opportunities it presents to corrections-based treatment are also explored in depth. Successful implementation of such strategies is likely to result in desirable health and social outcomes for both the inmate and the community at large.

Predictors of Continued Use of Extended-Released Naltrexone (XR-NTX) for Opioid-Dependence: An Analysis of Heroin and Non-Heroin Opioid Users in Los Angeles County

Extended-release naltrexone (XR-NTX) is associated with an increased number of opioid-free days, improved adherence rates in substance use disorder treatment programs, and reduced cravings and drug-seeking behaviors. There is little evidence on the predictive associations between baseline characteristics of opioid-dependent patients and XR-NTX utilization. Some studies have demonstrated better pharmacotherapy adherence and/or retention rates among non-heroin opioid users compared to heroin users. This study examines predictive associations between characteristics of patients and XR-NTX utilization, as well as participants' urge to use opiates. Our findings suggest that XR-NTX may contribute to decreases in urges to use among both heroin and non-heroin opioid users. Non-heroin opioid users and heroin users were retained in XR-NTX treatment for comparable periods of time. However, those who identified as homeless, injected opioids (regardless of opioid-type), or were diagnosed with a mental illness were less likely to be retained in treatment with XR-NTX.

Use of pharmacotherapies in the treatment of alcohol use disorders and opioid dependence in primary care

Substance-related and addictive disorders are chronic relapsing conditions that substantially impact public health. Effective treatments for these disorders require addressing substance use/dependence comprehensively as well as other associated comorbidities. Comprehensive addressing of substance use in a medical setting involves screening for substance use, addressing substance use directly with the patient, and formulating an appropriate intervention. For alcohol dependence and opioid dependence, pharmacotherapies are available that are safe and effective when utilized in a comprehensive treatment paradigm, such as medication assisted treatment. In primary care, substance use disorders involving alcohol, illicit opioids, and prescription opioid abuse are common among patients who seek primary care services. Primary care providers report low levels of preparedness and confidence in identifying substance-related and addictive disorders and providing appropriate care and treatment. However, new models of service delivery in primary care for individuals with substance-related and addictive disorders are being developed to promote screening, care and treatment, and relapse prevention. The education and training of primary care providers utilizing approved medications for the treatment of alcohol use disorders and opioid dependence in a primary care setting would have important public health impact and reduce the burden of alcohol abuse and opioid dependence.

Risk-taking propensity as a predictor of induction onto naltrexone treatment for opioid dependence

OBJECTIVE

Heroin addiction is a chronic relapsing disorder that has devastating social, medical, and economic consequences. Naltrexone is an antagonist that blocks opioid effects and could be an effective medication for the treatment of opioid dependence. However, its clinical utility has been limited partly because of poor adherence and acceptability. Given the importance of compliance to naltrexone treatment for opioid dependence, the goal of the current study was to examine predictors involved in successful induction onto naltrexone treatment.

METHOD

Parametric and nonparametric statistical tests were performed on data from a sample of 64 individuals entering treatment who met DSM-IV criteria for opioid dependence. The relationship between naltrexone induction (ie, inducted vs not inducted onto naltrexone) and risk-taking propensity, as indexed by riskiness on the Balloon Analogue Risk Task (BART), was examined. Participants were recruited from local detoxification programs, inpatient drug treatment, and other Baltimore programs that provided services to opioid-dependent adults (eg, Baltimore Needle Exchange Program) during the period from August 2007 to September 2008.

RESULTS

Positive association was shown between risk-taking propensity and odds of naltrexone induction. Specifically, each 5-point increase in the total BART score was associated with a 25% decrease in odds of naltrexone induction (OR = 0.76; 95% CI, 0.58-0.99; P = .041). This association remained statistically significant, even after adjusting for potential confounds, including injection drug use and cocaine positive urine results (P = .05). After adjusting for the covariates, each 5-point increase in BART score was associated with 28% decrease in the odds of achieving the maintenance dose (adjusted OR = 0.73; 95% CI, 0.54-0.99; P = .046).

CONCLUSIONS

Risk-taking propensity was predictive of induction onto naltrexone treatment, above and beyond injection drug use and cocaine-positive urine samples.

A multisite pilot study of extended-release injectable naltrexone treatment for previously opioid-dependent parolees and probationers

A feasibility study was conducted to pilot test the ability of 5 sites to recruit, treat, and retain opioid-dependent offenders in a trial of extended-release injectable naltrexone (XR-NTX). The participants, 61 previously opioid-dependent individuals under legal supervision in the community, received up to 6 monthly injections of Depotrex brand naltrexone and completed a 6-month follow-up interview. Six-month outcomes showed that those who completed treatment had significantly fewer opioid-positive urines and were less likely to have been incarcerated than those who had not completed treatment. The findings indicate that XR-NTX holds promise as a feasible, effective treatment option for opioid-dependent offenders.

Improving public health through access to and utilization of medication assisted treatment

Providing access to and utilization of medication assisted treatment (MAT) for the treatment of opioid abuse and dependence provides an important opportunity to improve public health. Access to health services comprising MAT in the community is fundamental to achieve broad service coverage. The type and placement of the health services comprising MAT and integration with primary medical care including human immunodeficiency virus (HIV) prevention, care and treatment services are optimal for addressing both substance abuse and co-occurring infectious diseases. As an HIV prevention intervention, integrated (same medical record for HIV services and MAT services) MAT with HIV prevention, care and treatment programs provides the best "one stop shopping" approach for health service utilization. Alternatively, MAT, medical and HIV services can be separately managed but co-located to allow convenient utilization of primary care, MAT and HIV services. A third approach is coordinated care and treatment, where primary care, MAT and HIV services are provided at distinct locations and case managers, peer facilitators, or others promote direct service utilization at the various locations. Developing a continuum of care for patients with opioid dependence throughout the stages MAT enhances the public health and Recovery from opioid dependence. As a stigmatized and medical disenfranchised population with multiple medical, psychological and social needs, people who inject drugs and are opioid dependent have difficulty accessing services and navigating medical systems of coordinated care. MAT programs that offer comprehensive services and medical care options can best contribute to improving the health of these individuals thereby enhancing the health of the community.

A randomized trial of oral naltrexone for treating opioid-dependent offenders

Offenders with a history of opioid dependence are a particularly difficult group to treat. A large proportion of offenders typically relapse shortly after release from prison, commit drug-related crimes, and then are arrested and eventually re-incarcerated. Previous research demonstrated that oral naltrexone was effective in reducing opioid use and preventing recidivism among offenders under federal supervision. The 111 opioid-dependent offenders in this study were under various levels of supervision that included county and federal probation/parole, a treatment court, an alternative disposition program, and an intermediate punishment program. Subjects were randomly assigned to receive 6 months of either 300 mg per week of oral naltrexone plus standard psychosocial treatment as usual (n = 56) or standard psychosocial treatment as usual (TAU) without naltrexone (n = 55). While the TAU subjects who remained in treatment used more opioids than the naltrexone subjects who remained, the high dropout rate for both groups made it difficult to assess the effectiveness of naltrexone. The study provides limited support for the use of oral naltrexone for offenders who are not closely monitored by the criminal justice system.

Treatment of medical, psychiatric, and substance-use comorbidities in people infected with HIV who use drugs

HIV-infected drug users have increased age-matched morbidity and mortality compared with HIV-infected people who do not use drugs. Substance-use disorders negatively affect the health of HIV-infected drug users, who also have frequent medical and psychiatric comorbidities that complicate HIV treatment and prevention. Evidence-based treatments are available for the management of substance-use disorders, mental illness, HIV and other infectious complications such as viral hepatitis and tuberculosis, and many non-HIV-associated comorbidities. Tuberculosis co-infection in HIV-infected drug users, including disease caused by drug-resistant strains, is acquired and transmitted as a consequence of inadequate prescription of antiretroviral therapy, poor adherence, and repeated interfaces with congregate settings such as prisons. Medication-assisted therapies provide the strongest evidence for HIV treatment and prevention efforts, yet are often not available where they are needed most. Antiretroviral therapy, when prescribed and adherence is at an optimum, improves health-related outcomes for HIV infection and many of its comorbidities, including tuberculosis, viral hepatitis, and renal and cardiovascular disease. Simultaneous clinical management of multiple comorbidities in HIV-infected drug users might result in complex pharmacokinetic drug interactions that must be adequately addressed. Moreover, interventions to improve adherence to treatment, including integration of health services delivery, are needed. Multifaceted, interdisciplinary approaches are urgently needed to achieve parity in health outcomes in HIV-infected drug users.

Medication-assisted treatment and HIV/AIDS: aspects in treating HIV-infected drug users

Drug use and HIV/AIDS remain serious public health issues in the US. The intersection of the twin epidemics of HIV and drug/alcohol use, results in difficult medical management issues for the healthcare providers who work in the HIV prevention and treatment fields. Access to care and treatment, medication adherence to multiple therapeutic regimens and concomitant drug-drug interactions of prescribed treatments are difficult barriers for drug users to overcome without directed interventions. Injection drug users are frequently disenfranchised from medical care and suffer stigma and discrimination creating additional barriers to care and treatment for their substance use disorders as well as HIV infection. Controlling the transmission of HIV will require access to care and treatment of individuals who abuse illicit drugs and alcohol. Improving health outcomes (e.g. access to and adherence to antiretroviral therapy) among HIV-infected substance users will also require access to evidenced-based pharmacological therapies for the treatment of drug abuse and dependence. The current review presents an overview of issues regarding the use of medication-assisted treatments for substance abuse and dependence among HIV-infected individuals, providing medical management paradigms for their care and treatment.

Clinical care of the HIV-infected drug user

HIV/AIDS and chemical dependency, the latter often intertwined with mental illness, are complex, overlapping spheres that adversely influence each other and the overall clinical outcomes of the affected individual. Each disorder individually impact tens of millions of people adversely, with explosive epidemics described worldwide. This article addresses the adverse consequences of HIV/AIDS, drug injection, the secondary comorbidities of both, and the impact of immunosuppression on presentation of disease as well as approaches to managing the HIV-infected drug user.

A systematic review of the effectiveness of naltrexone in the maintenance treatment of opioid and alcohol dependence

This systematic review summarises evidence of the effectiveness of naltrexone (NTX) and the added value of psychosocial treatment in the maintenance treatment of opioid and alcohol dependence. Studies were selected through a literature search conducted in March 2004. Seven opioid and seventeen alcohol studies were identified. When possible, meta-(regression) analyses were performed. There is lack of evidence about the effectiveness of NTX in the maintenance treatment of opioid dependence. There is evidence for the effectiveness and applicability of NTX in the management of alcohol dependence. The opioid studies combined NTX with a variety of psychosocial interventions, which plagued the evaluation of their value. Concomitant psychosocial interventions used in the alcohol studies were mainly cognitive behavioural, which seems to be more effective than NTX combined with supportive therapy. Available data do not allow firm conclusions regarding the added effect of psychosocial interventions. However, the data suggest that a combination of naltrexone with cognitive behavioural relapse prevention therapy is beneficial in alcohol dependent patients.

Treatment compliance in patients with comorbid psychiatric and substance use disorders

This study examines clinical and non-clinical factors associated with treatment compliance problems in 342 patients with substance use disorders (SUD) seen in routine psychiatric practice. Weighted Wald-X(2) and multivariate logistic regression assessed sociodemographic, clinical, treatment, and health plan characteristics associated with treatment compliance problems. Among patients with SUD, 40.5% were reported to currently have treatment compliance problems. Patients with treatment compliance problems were significantly more likely to have personality disorders, lower global assessment of functioning scores, and medication side effects than those without treatment compliance problems. Patients seen by psychiatrists who were reimbursed by discounted rather than undiscounted fee-for-service were five times more likely to be reported to have treatment compliance problems. Both clinical and non-clinical factors appear to be associated with treatment compliance problems. Understanding these factors and targeting treatment interventions may improve treatment compliance and patient outcomes.

Characteristics, retention and readmissions of opioid-dependent clients treated with oral naltrexone

The aims of this study were to examine the retention rates of opioid-dependent clients treated with oral naltrexone and identify factors that influence retention in treatment of 981 opioid-dependent clients at a public out-patient clinic in Perth, Western Australia. The average retention period for all clients was 9.0 weeks. The factors associated with longer retention were being employed and referral source. Clients who were employed stayed significantly longer in treatment than unemployed clients. Clients referred from a private clinic were retained in treatment significantly longer than those referred from other sources (X = 10.3 vs. 5.9 weeks). While the majority (80.8%) had one admission to naltrexone treatment, 19.2% presented for readmission, some on three or more occasions in the study period. The median period between the end of the first episode of treatment and commencement of the second was 15.6 weeks. The median period between the end of the second episode of treatment and commencement of the third was 11.4 weeks. Those employed had a higher probability of being retained longer in treatment than those who were unemployed in subsequent treatment episodes. Clinicians should expect that initial retention in naltrexone is likely to be relatively short, and that a substantial proportion of clients will represent for further treatment.

Improvement in naltrexone treatment compliance with contingency management

The efficacy of a voucher-based incentive program for improving adherence to outpatient, thrice weekly naltrexone maintenance was tested in a three group, randomized, 12-week clinical trial. Voucher incentives were given as follows: contingent group (n = 19) for each consecutive naltrexone dose ingested; non-contingent group (n = 19) on unpredictable schedule independently of taking naltrexone; no-voucher group (n = 20) none. Vouchers were exchangeable for goods and services. The contingent group had significantly longer treatment retention and ingested significantly more doses of naltrexone (consecutive and total) than either control group. Voucher incentives can significantly increase adherence to naltrexone maintenance in recently detoxified opioid dependent individuals.

Naltrexone pharmacotherapy for opioid dependent federal probationers

Federal probationers or parolees with a history of opioid addiction were referred by themselves or their probation/parole officer for a naltrexone treatment study. Participation was voluntary and subjects could drop out of the study at any time without adverse consequences. Following orientation and informed consent, 51 volunteers were randomly assigned in a 2:1 ratio to a 6-month program of probation plus naltrexone and brief drug counseling, or probation plus counseling alone. Naltrexone subjects received medication and counseling twice a week; controls received counseling at similar intervals. All therapy and medication were administered in an office located adjacent to the federal probation department. Fifty-two percent of subjects in the naltrexone group continued for 6 months and 33% remained in the control group. Opioid use was significantly lower in the naltrexone group. The overall mean percent of opioid positive urine tests among the naltrexone subjects was 8%, versus 30% for control subjects (p < .05). Fifty-six percent of the controls and 26% of the naltrexone group (p < .05) had their probation status revoked within the 6-month study period and returned to prison. Treatment with naltrexone and brief drug counseling can be integrated into the Federal Probation/Parole system with favorable results on both opioid use and re-arrest rates.

Pharmacological treatment of tobacco dependence

Pharmacologically based approaches for the treatment of tobacco dependence are reviewed. The rational basis for pharmacologic treatment approaches is that tobacco dependence is partially, and critically, mediated by the actions of tobacco-delivered nicotine to the central nervous system. These actions include direct reinforcing properties of nicotine itself, tolerance and physiologic dependence, possible beneficial effects of nicotine in the alleviation of anxiety and control of weight, and neurohormonal regulation which can become important to the maintenance of emotional well-being and performance at work. Insofar as tobacco abstinence leads to negative consequences, via these biobehavioral mechanisms, pharmacologic intervention should be able to assist in initial tobacco detoxification and help tobacco abstinent persons to avoid subsequent relapse. The purpose of this review is to survey some of the efforts to develop such interventions, as well as to elucidate some of the issues relevant to such development. Four distinct approaches are discussed: (1) Nicotine replacement, in which physiologic dependence is transferred to a safer and more therapeutically manageable nicotine delivering formulation; this category includes nicotine polacrilex gum; (2) Blockade therapy, in which a drug is taken that blocks the reinforcing properties of nicotine should relapse occur; (3) Nonspecific pharmacotherapy, in which the biobehaviorally mediated correlates of tobacco abstinence are treated on a symptomatic basis; (4) Deterrent therapy, in which a drug is taken prior to smoking such that any tobacco use would produce reliable aversive effects.

Chronic naltrexone supersensitizes the reinforcing and locomotor-activating effects of morphine

Rats were implanted for 10 days with a slow-release naltrexone pellet and then the pellet was removed. Sham-control animals were treated similarly, except no pellet was implanted. One day after pellet removal or sham treatment, animals were assessed for morphine-induced conditioned place preference (CPP) or locomotor activity. CPP was evident in sham animals following two conditioning trials using 5 mg/kg subcutaneous morphine (Experiment 1) and following one conditioning trial using 8 mg/kg intravenous morphine (Experiment 2). Animals conditioned while implanted with a naltrexone pellet showed no morphine-induced CPP. More important, one day after pellet removal, naltrexone-pretreated animals given one conditioning trial with 5 mg/kg intravenous morphine displayed a greater preference for morphine-associated cues relative to sham animals given morphine (Experiment 3 and 4). This single IV morphine dose was insufficient to produce CPP in sham animals, suggesting that naltrexone-induced supersensitization may only be evident at a morphine dose below the reinforcing threshold in control animals. Further, chronic naltrexone potentiated the locomotor-activating effect of 2 mg/kg subcutaneous morphine but not of either 1 or 5 mg/kg morphine (Experiment 5). Behavioral supersensitization assessed by morphine-induced locomotor activation was transient, as it was evident one day, but not either three or 10 days following pellet removal (Experiment 6). These results confirm the functional significance of opiate receptor up-regulation following chronic opioid blockade.

Retention and outcome in a narcotic antagonist treatment program

Investigations of outpatient narcotic antagonist programs have found high attribution rates when compared to such modalities as methadone. Moreover, outcome studies generally are lacking. The present study followed 50 patients through their course of treatment at an outpatient clinic of the Nassau County Department of Drug and Alcohol Addiction. Retention was found to average 69.22 days. This was slightly higher than the average found by other investigators. Patients in the present study who remained longer were similar demographically to those who dropped out early, but were found to enter treatment with more stable employment records and less recent opiate use. They also appeared more successful at termination, with better vocational stability, less extraneous drug use, and greater acceptance of referrals to other treatment. Identification of the needs of individuals at greater risk for premature termination can serve as a basis for refining treatment efforts.

Psychosocial factors in outcome in two opiate addiction treatments

Thirty naltrexone and 30 methadone patients in outpatient opiate addiction treatment were compared on pretreatment somatization, stress, and family support. Also, the relationship between these pretreatment variables and outcome in terms of drug abuse and retention was examined. In the methadone group, drug abuse was correlated significantly with somatization, stress, and family support. In the naltrexone group, retention was correlated significantly with somatization and stress. Treatment and research considerations were discussed.

Endogenous opiates: 1983

This paper is the sixth in an annual series of reviews of research involving the endogenous opiates, each installment being restricted to work published during the previous year. Although the early articles in the series attempted to be comprehensive and cover the complete range of research with the opiate peptides, in the last two years we have limited our coverage to non-analgesic and behavioral work due to the enormous number of articles published in the field. The specific areas discussed here include stress, tolerance and dependence, consummatory responses, other gastrointestinal functions, interactions with alcohol, mental illness, learning and memory, cardiovascular responses, respiratory effects, thermoregulation, neurological disorders, activity, and miscellaneous other topics. As in previous years, we have attempted to present a relatively complete review of the subjects covered only for the previous year and generally have not tried to evaluate their contributions relative to those of past years.