Patterns of sustained heroin abstinence amongst long-term, dependent heroin users: 36 months findings from the Australian Treatment Outcome Study (ATOS)

Evaluation of real-world outcomes associated with use of a prescription digital therapeutic to treat substance use disorders

BACKGROUND AND OBJECTIVES

Digital therapeutics can expand the reach and fidelity of behavioral treatment for substance use disorders (SUDs). This analysis evaluated real-world engagement and clinical outcomes in patients diagnosed with SUD who were prescribed reSET®, an FDA-authorized prescription digital therapeutic (PDT).

METHODS

Patients were prescribed a 12-week PDT comprising 61 therapy lessons (31 "core" and 30 "keep learning" lessons) and contingency management rewards (positive reinforcement message or monetary gift cards) based on lesson completion and negative urine drug screens. Engagement (defined as any activity in the PDT), retention (any activity in Weeks 9-12), and substance use data were collected automatically by the PDT and analyzed descriptively. Associations between early lesson completion and end-of-treatment outcomes were assessed.

RESULTS

Six hundred and fifty-eight patients filled their prescription. Evaluated were 602 patients who were exposed to therapeutic content by completing at least one lesson (median age 37 years, 33% female, 41% male, 26% unreported sex). Median lessons completed was 33 (out of 61 possible), and 52% of patients completed all core modules. Retention in treatment during the last 4 weeks of treatment was 74%, and 62% were abstinent (missing data considered positive). [Correction added on 13 December 2022, after first online publication: In the preceding sentence, the treatment percentage values were revised from 74.6% to 74%.] DISCUSSION AND CONCLUSIONS: Patients with SUD exhibited robust engagement with a PDT, high rates of retention through 12 weeks, and substantial rates of abstinence at end of treatment when the therapeutic was used in a real-world setting. PDT's hold promise as a new way to access effective SUD treatment.

SCIENTIFIC SIGNIFICANCE

This study is the first to report real-world PDT engagement and clinical outcomes data from a large, geographically diverse population of patients with SUDs.

Lower buprenorphine elimination rate constant is associated with lower opioid use

BACKGROUND

Opioid craving is suggested to correlate with the rate of reduction in buprenorphine (BUP) plasma levels. No studies explored Buprenorphine elimination rate constant (BUP EL.R) as a predictor of opioid use or retention in BUP treatment.

METHODS

Analysis was performed using data from a randomized controlled trial of 141 adults with opioid use disorder (OUD) randomized to Incentivized Adherence and Abstinence monitoring (I-AAM; experimental (n = 70) and treatment-as-usual; control (n = 71). In the I-AAM, structured access to unsupervised BUP doses was provided up to 28 days contingent of adherence measured by Therapeutic Drug Monitoring and abstinence by Urinary Drug Screens (UDS). In contrast, the treatment-as-usual (control) provided unstructured access to unsupervised doses was provided for up to 14 days considering UDS results. The primary outcome was percentage negative UDS. The secondary outcome, retention in treatment, was continuous enrollment in the study and analysis was via intention-to-treat. Significant bivariate correlations with the outcomes were adjusted for group allocation.

RESULTS

A significant negative correlation between BUP EL.R and percentage negative opioid screens (Pearson correlation coefficient - 0.57, p < 0.01) was found. After adjusting for trial group, BUP EL.R was shown to be an independent predictor of percentage negative opioid screens (Standardized Beta Coefficient - 0.57, 95% CI - 221.57 to - 97.44, R² 0.322).

CONCLUSION

BUP EL.R predicted 32.2% of the variation in percentage negative opioid UDS and may serve as a potential promising tool in precision medicine of BUP treatment. Higher buprenorphine elimination is associated with higher positive opioid urine screens during treatment.

TRIAL REGISTRATION

ISRCTN41645723 retrospectively registered on 15/11/2015.

Effects of a Residential Multimodal Psychological Treatment in an Addicted Population, at 6 and 12 Months: Differences Between Men and Women

The aim of this study is to explore the effects of a residential multimodal treatment intervention for an addict population. We gathered participants from the "Programa Base" (n = 166) of the Solidarity and Reinsertion Foundation of Murcia, and assessed the various problematic areas with the EuropASI at baseline level, 6 months and 12 months of treatment. We found improved outcomes in every area except for Legal Status. In addition, we found differences between male and female participants in their baseline evaluation, as well as between completers and non-completers. In conclusion, this data shows us some changes which occurred in individuals with problematic drug use during treatment, going further into the complex social reality which causes great suffering and damage to people and their families.

Sex Differences in Opioid and Psychostimulant Craving and Relapse: A Critical Review

A widely held dogma in the preclinical addiction field is that females are more vulnerable than males to drug craving and relapse. Here, we first review clinical studies on sex differences in psychostimulant and opioid craving and relapse. Next, we review preclinical studies on sex differences in psychostimulant and opioid reinstatement of drug seeking after extinction of drug self-administration, and incubation of drug craving (time-dependent increase in drug seeking during abstinence). We also discuss ovarian hormones' role in relapse and craving in humans and animal models and speculate on brain mechanisms underlying their role in cocaine craving and relapse in rodent models. Finally, we discuss imaging studies on brain responses to cocaine cues and stress in men and women.The results of the clinical studies reviewed do not appear to support the notion that women are more vulnerable to psychostimulant and opioid craving and relapse. However, this conclusion is tentative because most of the studies reviewed were correlational, not sufficiently powered, and not a priori designed to detect sex differences. Additionally, imaging studies suggest sex differences in brain responses to cocaine cues and stress. The results of the preclinical studies reviewed provide evidence for sex differences in stress-induced reinstatement and incubation of cocaine craving but not cue- or cocaine-induced reinstatement of cocaine seeking. These sex differences are modulated in part by ovarian hormones. In contrast, the available data do not support the notion of sex differences in craving and relapse/reinstatement for methamphetamine or opioids in rodent models. SIGNIFICANCE STATEMENT: This systematic review summarizes clinical and preclinical studies on sex differences in psychostimulant and opioid craving and relapse. Results of the clinical studies reviewed do not appear to support the notion that women are more vulnerable to psychostimulant and opioid craving and relapse. Results of preclinical studies reviewed provide evidence for sex differences in reinstatement and incubation of cocaine seeking but not for reinstatement or incubation of methamphetamine or opioid seeking.

Patient Characteristics Associated with Opioid Abstinence after Participation in a Trial of Buprenorphine versus Injectable Naltrexone

Background and Objectives: Better understanding of predictors of opioid abstinence among patients with opioid use disorder (OUD) may help to inform interventions and personalize treatment plans. This analysis examined patient characteristics associated with opioid abstinence in the X:BOT (Extended-Release Naltrexone versus Buprenorphine for Opioid Treatment) trial. Methods: This post-hoc analysis examined factors associated with past-month opioid abstinence at the 36-week follow-up visit among participants in the X:BOT study. 428 participants (75% of original sample) attended the visit at 36 weeks. Logistic regression models were used to estimate the probability of opioid abstinence across various baseline sociodemographics, clinical characteristics, and treatment variables. Results: Of the 428 participants, 143 (33%) reported abstinence from non-prescribed opioids at the 36-week follow-up. Participants were more likely to be opioid abstinent if randomized to XR-NTX (compared to BUP-NX), were on XR-NTX at week 36 (compared to those off OUD pharmacotherapy), successfully inducted onto either study medication, had longer time on study medication, reported a greater number of abstinent weeks, or had longer time to relapse during the 24-week treatment trial. Participants were less likely to be abstinent if Hispanic, had a severe baseline Hamilton Depression Rating (HAM-D) score, or had baseline sedative use. Conclusions: A substantial proportion of participants was available at follow-up (75%), was on OUD pharmacotherapy (53%), and reported past-month opioid abstinence (33%) at 36 weeks. A minority of patients off medication for OUD reported abstinence and additional research is needed exploring patient characteristics that may be associated with successful treatment outcomes.

Predictors of Relapse to Alcohol and Substance Use: Are There Any Differences between 3 and 12 Months after Inpatient Treatment?

Understanding the factors that lead to relapse is important for developing effective treatment strategies. The aim of this study is to examine sociodemographic and clinical factors that predict relapse 3 and 12 months after inpatient treatment in patients with alcohol and substance use disorders. 247 patients were included in the study. A sociodemographic data form and the Addiction Profile Index-Clinical Form (API-C) were filled out during the first days of hospitalization and relapse information was obtained through outpatient interviews. Logistic regression analysis was used to assess predictive factors. Rates of relapse for the 3^rd and 12^th months were 40.5% and 74.6%, respectively. Motivation to quit substance use, risk of depression, being on probation, and being employed predicted relapse within the 3-month period. At the 12^th month, substance use intensity and motivation to quit were the factors associated with relapse. To conclude, motivation to quit is critical to maintaining both early and sustained remission. Moreover, divergent factors may be relevant at different stages of treatment. Defining relapse predictors early in the process and being vigilant to the change in the needs of patients as the treatment continues may help to develop a more effective and focused treatment plan.

Opium dependence and the potential impact of changes in treatment coverage level: A dynamic modeling study

Background : The most common drug, illegally used in Iran is opium. The treatment of people with substance use disorder is one of the most important strategies in reducing its burden. The aim of this study was to investigate the effect of different increasing and decreasing opium treatment coverage on the patterns of abstinence, transition to heroin dependence and mortality, over 30 years. Methods: This study was a dynamic compartmental modeling conducted in three stages: 1) presenting a conceptual model of opium dependence treatment in Iran, 2) estimating model's parameters value, and 3) modeling of opium dependence treatment and examining the outcomes for different treatment coverage scenarios. The input parameters of the model were extracted from the literature, and secondary data analysis, which were finalized in expert panels. Results: The number of opium dependence will increase from 1180550 to 1522063 [28.93% (95% CI: 28.6 to 29.2)] over 30 years. With a 25% decrease in coverage compared to the status quo, the number of deaths will increase by 459 cases [3.28% (95% CI: 0.91 to 5.7)] in the first year, and this trend will continue to be 2989 cases [15.63% (95% CI: 13.4 to 17.9)] in the 30th year. A 25% increase in treatment coverage causes a cumulative decrease of heroin dependence by 14451 cases [10.1% (95% CI: 9.5 to 10.8)] in the first decade. Conclusion: The modeling showed that the treatment coverage level reduction has a greater impact than the coverage level increase in the country and any amount of reduction in the coverage level, even to a small extent, may have a large negative impact in the long run.

Frequency of and Factors Associated With Nonmedical Opioid Use Behavior Among Patients With Cancer Receiving Opioids for Cancer Pain

Importance

One of the main aims of research on nonmedical opioid use (NMOU) is to reduce the frequency of NMOU behaviors through interventions such as universal screening, reduced opioid exposure, and more intense follow-up of patients with elevated risk. The absence of data on the frequency of NMOU behavior is the major barrier to conducting research on NMOU.

Objective

To determine the overall frequency of and the independent predictors for NMOU behavior.

Design, Setting, and Participants

In this prognostic study, 3615 patients with cancer were referred to the supportive care center at MD Anderson Cancer Center from March 18, 2016, to June 6, 2018. Patients were eligible for inclusion if they had cancer and were taking opioids for cancer pain for at least 1 week. Patients were excluded if they had no follow-up within 3 months of initial consultation, did not complete the appropriate questionnaire, or did not have scheduled opioid treatments. After exclusion, a total of 1554 consecutive patients were assessed for NMOU behavior using established diagnostic criteria. All patients were assessed using the Edmonton Symptom Assessment Scale, the Screener and Opioid Assessment for Patients with Pain (SOAPP), and the Cut Down, Annoyed, Guilty, Eye Opener-Adapted to Include Drugs (CAGE-AID) survey. Data were analyzed from January 6 to September 25, 2020.

Results

A total of 1554 patients (median [interquartile range (IQR)] age, 61 [IQR, 52-69] years; 816 women [52.5%]; 1124 White patients [72.3%]) were evaluable for the study, and 299 patients (19.2%) had 1 or more NMOU behaviors. The median (IQR) number of NMOU behaviors per patient was 1 (IQR, 1-3). A total of 576 of 745 NMOU behaviors (77%) occurred by the first 2 follow-up visits. The most frequent NMOU behavior was unscheduled clinic visits for inappropriate refills (218 of 745 [29%]). Eighty-eight of 299 patients (29.4%) scored 7 or higher on SOAPP, and 48 (16.6%) scored at least 2 out of 4 points on the CAGE-AID survey. Results from the multivariate model suggest that marital status (single, hazard ratio [HR], 1.58; 95% CI, 1.15-2.18; P = .005; divorced, HR, 1.43; 95% CI, 1.01-2.03; P = .04), SOAPP score (positive vs negative, HR, 1.35; 95% CI, 1.04-1.74; P = .02), morphine equivalent daily dose (MEDD) (HR, 1.003; 95% CI, 1.002-1.004; P < .001), and Edmonton Symptom Assessment Scale pain level (HR, 1.11; 95% CI, 1.06-1.16; P < .001) were independently associated with the presence of NMOU behavior. In recursive partition analysis, single marital status, MEDD greater than 50 mg, and SOAPP scores greater than 7 were associated with a higher risk (56%) for the presence of NMOU behavior.

Conclusions and Relevance

This prognostic study of patients with cancer taking opioids for cancer pain found that 19% of patients developed NMOU behavior within a median duration of 8 weeks after initial supportive care clinic consultation. Marital status (single or divorced), SOAPP score greater than 7, higher levels of pain severity, and MEDD level were independently associated with NMOU behavior. This information will assist clinicians and investigators designing clinical and research programs in this important field.

Real-world evidence for a prescription digital therapeutic to treat opioid use disorder

OBJECTIVES

To evaluate patient engagement and usage of a prescription digital therapeutic (PDT) and associated outcomes of opioid use and treatment retention in a large real-world dataset of patients with opioid use disorder (OUD) treated with buprenorphine medication for opioid use disorder (MOUD). PDTs are software-based disease treatments evaluated for safety and effectiveness in randomized clinical trials (RCTs), and authorized by the U.S. Food and Drug Administration (FDA) to treat disease with approved directions for use (label).

METHODS

A real-world observational evaluation of an all-comer population of patients who redeemed a 12-week prescription for the reSET-O PDT. Engagement and therapeutic use data were collected and analysed on a population level. Substance use was evaluated as a composite of self-reports recorded with reSET-O and urine drug screens (UDS).

RESULTS

Data from 3144 individuals with OUD were evaluated. 45.5% were between ages 30 and 39 years. 80% completed at least 8 of the 67 possible therapeutic modules, 66% completed half of all modules, and 49% completed all modules. Abstinence during the last 4 weeks of treatment was calculated with two imputation methodologies: 66% abstinent using "missing data excluded (patients with no data as positive)", and 91% abstinent with "missing data removed (patients with no data excluded)". 91% of patients met the responder definition of ≥80% of self-report or UDS negative. 74.2% of patients were retained through the last 4 weeks of treatment. Subgroup analysis of patients using reSET-O appropriately (4 or more modules per week for the first 4 weeks) showed 88.1% abstinence using "missing data excluded (patients with no data as positive)", and retention at weeks 9-12 of 85.8%.

CONCLUSIONS

Results demonstrate that reSET-O is readily and broadly used by patients with OUD and that high real-world engagement with the therapeutic is positively associated with abstinence and retention in treatment. ReSET-O is a potentially valuable adjunct to buprenorphine MOUD therapy for patients with OUD.

Long term pre-treatment opioid use trajectories in relation to opioid agonist therapy outcomes among people who use drugs in a Canadian setting

BACKGROUND

Opioid agonist therapy (OAT) models are generally provided without consideration of how pre-treatment characteristics may be associated with outcome. Therefore, we aimed to first characterize longitudinal trajectories of opioid use before initiating OAT. Then we explored the impact of OAT on opioid use across these pre-treatment trajectories.

METHODS

Data were derived from three prospective cohort studies involving people who use drugs in Vancouver, Canada. Latent class growth analysis was applied to identify opioid use trajectories based on individual-level observations three years before starting OAT. Multivariable generalized linear mixed model was used to examine whether engaging in OAT was associated with lower risk of illicit opioid use among participants with different pre-treatment opioid use trajectories.

RESULTS

464 participants were included in the study between September 2005 and November 2018. Two pre-treatment opioid use trajectories were identified: high frequency users (246, 53.0%) and gradually increasing frequency users (218, 47.0%). We observed different strengths of association between OAT engagement and illicit opioid use among high frequency users (adjusted odds ratio [AOR] = 0.36, 95% Confidence Interval [CI]: 0.20 - 0.63) and gradually increasing frequency users (AOR = 0.91, 95% CI: 0.53 - 1.56). Unstable housing, any stimulant use, experiencing violence, drug dealing, sex work involvement, and incarceration were independently and positively associated with ongoing illicit opioid use.

CONCLUSIONS

Distinct pre-treatment opioid use trajectories are likely to influence treatment outcomes. Research is required to determine if tailored strategies specific to people with different pre-treatment opioid use patterns have potential to improve outcomes of OAT.

Dopamine D3 receptor-based medication development for the treatment of opioid use disorder: Rationale, progress, and challenges

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Opioid abuse and overdose have become a national crisis in the USA.

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Although several opioid-based pharmacotherapies are available, they are ineffective in long-term relapse prevention.

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National Institute on Drug Abuse has listed dopamine D3 receptor antagonists as high priority for anti-opioid medication development.

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The novel D3 receptor antagonists (VK4-116, VK4-40) are effective in reducing opioid reward and relapse as well as potentiate opioid analgesia.

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D3 receptor antagonists deserve further studies as new pharmacotherapies for pain and of opioid use disorder.

Opioid abuse and related overdose deaths continue to rise in the United States, contributing to the current national opioid crisis. Although several opioid-based pharmacotherapies are available (e.g., methadone, buprenorphine, naloxone), they show limited effectiveness in long-term relapse prevention. In response to the opioid crisis, the National Institute on Drug Abuse proposed a list of pharmacological targets of highest priority for medication development for the treatment of opioid use disorders (OUD). Among these are antagonists of dopamine D3 receptors (D3R). In this review, we first review recent progress in research of the dopamine hypothesis of opioid reward and abuse and then describe the rationale and recent development of D3R ligands for the treatment of OUD. Herein, an emphasis is placed on the effectiveness of newly developed D3R antagonists in the animal models of OUD. These new drug candidates may also potentiate the analgesic effects of clinically used opioids, making them attractive as adjunctive medications for pain management and treatment of OUD.

Trajectories of injection drug use among people who use drugs in Vancouver, Canada, 1996-2017: growth mixture modeling using data from prospective cohort studies

BACKGROUND AND AIMS

Injection drug use patterns are known to change over time, although such long-term changes have not been well described. We sought to characterize longitudinal trajectories of injection drug use and identify associated factors.

DESIGN

Data were derived from the Vancouver Injection Drug Users Study and AIDS Care Cohort to evaluate the Exposure to Survival Services study, two prospective cohorts involving people who inject drugs in Vancouver, Canada between 1996 and 2017. Growth mixture modeling was applied to identify distinct injection drug use trajectories. Multinomial logistic regression was used to identify baseline factors associated with each trajectory.

SETTING

Canada.

PARTICIPANTS

A total of 2057 participants who reported having used illicit drugs via injection in the past 6 months at the baseline visit were included in the study. The median time since first injection drug use at baseline was 14.8 years (quartile 1-quartile 3: 6.5-24.3).

MEASUREMENTS

Information regarding self-reported injection drug use during the past 6 months was collected at baseline and semi-annually thereafter via interviewer-administered questionnaires.

FINDINGS

Participants were followed for a median of 113.4 months (quartile 1-quartile 3: 63.4-161.7). Five trajectories were identified: persistent high frequency injection (507, 24.6%); high frequency injection with late decrease (374, 18.2%); gradual cessation (662, 32.2%); early cessation with late relapse (227, 11.0%); and early cessation (287, 14.0%). Factors found to be associated with distinct trajectories included: daily heroin injection, binge injection drug use, age, not being in a stable relationship and year of study enrollment.

CONCLUSIONS

People who used drugs in Vancouver, Canada from 1996 to 2017 appeared to follow five drug use trajectories, ranging from persistent high frequency use to early cessation. Almost 25% of participants remained high-frequency injectors over the study period.

Measurement-based care using DSM-5 for opioid use disorder: can we make opioid medication treatment more effective?

CONTEXT AND PURPOSE

Measurement-based care (MBC) is an evidence-based health-care practice in which indicators of disease are tracked to inform clinical actions, provide feedback to patients and improve outcomes. The current opioid crisis in multiple countries provides a pressing rationale for adopting a basic MBC approach for opioid use disorder (OUD) using DSM-5 to increase treatment retention and effectiveness.

PROPOSAL

To stimulate debate, we propose a basic MBC approach using the 11 symptoms of OUD (DSM-5) to inform the delivery of medications for opioid use disorder (MOUD; including methadone, buprenorphine and naltrexone) and their evaluation in office-based primary care and specialist clinics. Key features of a basic MBC approach for OUD using DSM-5 are described, with an illustration of how clinical actions are guided and outcomes communicated. For core treatment tasks, we propose that craving and drug use response to MOUD should be assessed after 2 weeks, and OUD remission status should be evaluated at 3, 6 and 12 months (and exit from MOUD treatment) and beyond. Each of the 11 DSM-5 symptoms of OUD should be discussed with the patient to develop a case formulation and guide selection of adjunctive psychological interventions, supplemented with information on substance use, and optionally extended with information from other clinical instruments. A patient-reported outcome measure should be recorded and discussed at each remission assessment.

CONCLUSIONS

MBC can be used to tailor and adapt MOUD treatment to increase engagement, retention and effectiveness. MBC practice principles can help promote patient-centred care in OUD, personalized addiction therapeutics and facilitate communication of outcomes.

Predictors of treatment participation rate of substance use disorders among Whites and African Americans

Low treatment participation impedes successful treatment completion and reduces treatment effectiveness. This study explored relationships among treatment participation rate and individuals' symptom severities and employment statuses. A sample of 106 individuals with substance use disorders was recruited for cross-sectional investigation. Individuals who were employed at baseline or had lower symptom severities of baseline alcohol, drug use, and psychiatric issues had significantly higher treatment participation rates. Service providers should pay more attention to individuals' symptom severities and employment to encourage treatment participation. Integrated interventions including vocational services and illness management and recovery intervention could be provided to reduce individuals' symptom severities and increase employability. Implications of participation in substance abuse treatment are discussed.

Correlates of Long-Term Opioid Abstinence After Randomization to Methadone Versus Buprenorphine/Naloxone in a Multi-Site Trial

Opioid use disorder (OUD) is a chronic, relapsing condition with severe negative health consequences. Previous studies have reported that 5-year opioid abstinence is a good predictor of reduced likelihoods of relapse, but factors that shape long-term opioid abstinence are poorly understood. The present study is based on data from a prospective study of 699 adults with OUD who had been randomized to either methadone or buprenorphine/naloxone and who were followed for at least 5 years. During the 5 years prior to the participants' last follow-up interview, 232 (33.2%) had achieved 5-year abstinence from heroin. Of those 232, 145 (20.7% of the total) had remained abstinent from both heroin and other opioids (e.g., hydrocodone, oxycodone, other opioid analgesics, excluding methadone or buprenorphine). Compared to non-abstinent individuals, those in both categories of opioid abstinence had lower problem severity in health and social functioning at the final follow-up. Logistic regression results indicated that cocaine users and injection drug users were less likely to achieve 5-year heroin abstinence, whereas Hispanics (vs. whites) and those treated in clinics on the West Coast (vs. East) were less likely to achieve 5-year abstinence from heroin and other opioids. For both abstinence category groups, abstinence was positively associated with older age at first opioid use, lower impulsivity, longer duration of treatment for OUD, and greater social support. Reducing cocaine use and injection drug use and increasing social support and retention in treatment may help maintain long-term abstinence from opioids among individuals treated with agonist pharmacotherapy.

Predictors of transitions across stages of heroin use and dependence prior to treatment-seeking among people in treatment for opioid dependence

BACKGROUND AND AIMS

Little is known about transition pathways among heroin users prior to treatment. This study examined the demographic and clinical predictors of transition speed from heroin use, to dependence, to first treatment episode.

METHODS

1149 heroin-dependent participants recruited from opioid agonist treatment clinics in Sydney, Australia, underwent a structured interview. Age of onset (AOO) was collected for heroin use, dependence and treatment-seeking, childhood maltreatment, psychiatric history and other substance dependence. Discrete-time survival analyses modelled years from onset of use to dependence, and from dependence to treatment-seeking, including demographic and clinical covariates.

FINDINGS

Median AOO for first heroin use, dependence and treatment-seeking was 18 years (inter-quartile range, or IQR = 6), 21 years (IQR = 7), and 24 years (IQR = 10) respectively. In adjusted models, younger birth cohorts (vs. born <1960), greater childhood maltreatment and later AAO of first heroin use were associated with more rapid transitions from heroin use to dependence. Living independently, parental violence, and alcohol dependence were associated with slower transitions. Earlier treatment-seeking was associated with younger birth cohorts, having dependent children and later AOO of dependence. Delayed treatment-seeking was associated with <10 years school education, living independently, depression and alcohol dependence.

CONCLUSIONS

In this treatment sample, onset of heroin use occurred during late adolescence, suggesting the need for targeted interventions in mid-adolescence. Transitions to heroin dependence, then treatment-seeking, occurred during early adulthood. Rapid transitions from use to dependence were associated with younger birth cohorts, greater exposure to childhood maltreatment, and later onset of use.

Changes in opiate and stimulant use through 10 years: The role of contextual factors, mental health disorders and psychosocial factors in a prospective SUD treatment cohort study

AIM

To examine temporal changes in opiate and stimulant use among patients in substance abuse treatment over a ten-year observation period and to explore the role of contextual factors, mental health disorders and psychosocial factors on these changes.

METHODS

A cohort of 481 patients was prospectively interviewed at admission to treatment and after 1, 2, 7 and 10 years. The sample was recruited from 20 facilities in the Greater Oslo region, Norway.

RESULTS

The majority of patients were poly-drug users and 80% had used both opiates and stimulants the last 30 days prior to treatment admission. Last-month use of heroin, other opiates, cocaine and amphetamines declined from 80% to 34% at the end of the observation period. The most substantial reduction was observed between baseline and one-year follow-up. Use of heroin decreased the most from 62% to 16% after 10 years (a reduction of 74%), and the reduction continued from one-year follow-up throughout the observation period. The most important multivariate risk factors for sustained use of these drugs were male gender, having one or both biological parents with severe alcohol or drug problems, having an antisocial personality disorder, and living together with a person who abuses alcohol or drugs. Employment was associated with reduced risk of drug use at 7-year follow-up.

CONCLUSIONS

There was a substantial reduction in opiate and stimulant use from baseline to all follow-up assessments, most greatly for heroin. Findings regarding sustained use could suggest familial transmission and the challenges of preventive strategies and treatment efforts in an intergenerational context. Co-occurrence between drug abuse and mental health problems highlights the need of highly specialized competence in SUD treatment.

Large variation in measures used to assess outcomes of opioid dependence treatment: A systematic review of longitudinal observational studies

ISSUES

Treatment outcomes for drug users are critical for informing policy and therapeutic practice. The coherence of outcomes, changes and drug use measures from observational studies on opioid use treatment were reviewed.

APPROACH

Systematic review of the literature for longitudinal observational studies, from 1980 through November 2015, in all languages, with data on treated opioid users, using Pubmed, the Cochrane Library and additional strategies (e.g. Pubmed function 'related citations' and checking reference lists of eligible studies).

KEY FINDINGS

Twenty-seven studies were included (11 countries, 85 publications, recruitment 1962-2009). Baseline n was >65 686 and median follow-up 34.5 months (21 studies) or 51.4 person-months (10 studies). Eight outcome domains were identified: 'drug use' (21/27 studies), 'crime' (13), 'health' (13), 'treatment-related' outcomes (16), 'social functioning' (13), 'harms' (8), 'mortality' (13) and 'economic estimates' (2 studies). All studies using drug use outcomes included a binary (abstinence) category in at least one measure. Studies typically reported outcomes on less than half (on average 3.7 or 46%) of the eight outcome domains, while the average was 5.1 (64%) in seven studies initiated since 2000.

IMPLICATIONS AND CONCLUSION

Wide variation exists in outcome measures found in longitudinal observational studies of treatment of opioid users. This reduces replicability of studies and suggests a lack of common expectations on treatment success. Future studies should consider using all or most of eight outcome domains identified (excluding economic analyses if unfeasible), non-binary measures and amount/value of drugs used and consensus meetings with joint ownership of scientific, treatment and patient communities.

A prospective cohort study of hospital separations among people who inject drugs in Australia: 2008-2013

OBJECTIVES

Injecting drug use is a persistent behaviour that increases the risk of morbidities and mortality. We assessed the burden of hospital separations among people who inject drugs (PWID), the excess compared to the general population and characteristics of separations associated with frequent use.

DESIGN

Prospective cohort study.

SETTING

All public and private hospitals in Victoria.

PARTICIPANTS

757 community-based PWID with hospital separations between January 2008 and June 2013 identified through record linkage, who contributed over 3729 person-years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Counts, proportions and rates of hospital separations, descriptive administrative data including all diagnoses, comparison of separation rates to the general population, trend in separations and factors associated with frequent separations.

RESULTS

There were 2106 separations in the cohort. The most common principal diagnoses were related to mental and behavioural disorders (31%), but social circumstances influencing health was the most common group of diagnoses (61%) when all contributing diagnoses for each patient were considered. Separation rates were up to three times higher than in the age-matched population, and there was a 12% increase in separations every 6 months. Over a quarter (29%) of the cohort had frequent separations (defined as two or more separations in a calendar year), which were associated with mental health-related diagnoses, being discharged to locations other than a patient's residence, having a medical as opposed to surgical intervention, seasonal patterns, relationship status and gender.

CONCLUSIONS

Mental health conditions and other characteristics associated with separations and frequent separations in particular, emphasise the importance of providing referrals to harm reduction, social services and mental health services at discharge in order to reduce excess hospital separations among PWID.

Effectiveness of treatment for opioid use disorder: A national, five-year, prospective, observational study in England

BACKGROUND

This the first 5-year effectiveness study of publicly funded treatment for opioid use disorder (OUD) in England.

METHODS

All adults initiating treatment in 2008/09 in all 149 local treatment systems reporting to the National Drug Treatment Monitoring System (n=54,347). Admission polydrug use sub-populations were identified by Latent Class Analysis. The treatment outcome measure was 'successful completion and no re-presentation within six months' (SCNR) analysed by multilevel, multivariable logistic regression and funnel plots to contrast outcome by treatment system.

RESULTS

SCNR was achieved by 21.9%. Heroin and crack cocaine users were significantly less likely to achieve this outcome than patients who used heroin only (adjusted odds ratio [AOR] 0.90; 95% confidence interval [CI] 0.85-0.95). Older patients (AOR 1.09; CI 1.07-1.11), those employed (AOR 1.27; CI 1.18-1.37) and those enrolled for longer treatment were more likely to achieve the outcome measure. After risk adjustment, the local treatment systems that achieved substantially better outcome performance (14/149) had a lower rate of opiate prevalence in the local population at time of study initiation (incidence rate difference [IRD] 4.1; CI 4.0-4.2), fewer criminal offences per thousand (IRD 28.5; CI 28.1-28.8) and lower drug-related deaths per million (IRD 5.9; CI 5.9-5.9).

CONCLUSIONS

In an English national study, one fifth of patients successful completed treatment for OUD and did not present for further treatment within six months. Longer time in treatment increases the probability of achieving and maintaining clinical benefit from treatment. After risk-adjustment, an important minority of treatment systems achieve substantially better outcome performance.

Gender Differences and Correlated Factors of Heroin Use Among Heroin Users

BACKGROUND

Gender differences in illicit drug use are becoming increasingly recognized. However, there are few studies concerning differences between male and female heroin users in China.

OBJECTIVES

The study aimed to explore gender differences in terms of socio-demographic characteristics, drug-related behaviors, and treatment history among a heroin-using population in China.

METHODS

A cross-sectional study was conducted in four cities in December 2013. A total of 788 participants were recruited from several types of sites in each city: compulsory detoxification centers, methadone maintenance treatment clinics, and detention facilities. The data were collected via a self-administered questionnaire. Analysis of variance, chi-square test, and multivariate logistic regression analyses were conducted to examine gender differences in socio-demographic characteristics, drug-related behaviors, and treatment history.

RESULTS

Female heroin users were more likely to be unemployed, have more education, and use heroin with their spouse/companion (p <.05). Male heroin users were more likely to be in detention facilities and MMT clinics, and relapse when they felt hopeless (p <.05). Conclusions/Importance: Although there were some similarities between male and female heroin users, significant gender differences do exist in some aspects of socio-demographic characteristics and heroin use. The data provide evidence that interventions aimed at preventing the initiation of heroin use and reducing relapse should take gender into account.

Remission from substance use disorders: A systematic review and meta-analysis

OBJECTIVE

This paper presents a systematic review and meta-analysis of available evidence on remission rates for substance use disorders (SUDs), providing weighted mean estimates of SUD remission rates. The review also explores study-level characteristics that may explain variations in remission rates across studies.

METHODS

A comprehensive search strategy identified studies published between 2000 and 2015 with follow-up periods of at least three years or reported lifetime remission outcomes for potential inclusion in the review. Remission was defined as not meeting diagnostic criteria for abuse or dependence for a minimum period of six months, as of final follow-up. A single-group summary meta-analysis was performed. Pooled estimated annual remission rates (PEARRs) were calculated. Meta-regression techniques and subgroup analyses were used to explore the association between study remission rates and key selected variables.

RESULTS

Of 8855 studies identified, 21 met the eligibility criteria. The results suggested that 35.0% to 54.4% of individuals with SUDs achieved remission, and this occurred after a mean follow-up period of 17 years. The PEARRs projected few cases of SUD remission, between 6.8% and 9.1% in any given year. Studies that reported higher remission rates had longer follow-up periods, and lower sample retention rates.

CONCLUSIONS

Results support the contention that SUDs are more likely to be "chronic" or long term disorders than acute disorders for a substantial number of individuals. However, more longitudinal research is required. Treatment geared to chronicity, such as assertive community treatment and intensive case management, needs to be more readily available for SUD populations.

Buprenorphine Initiation and Linkage to Outpatient Buprenorphine do not Reduce Frequency of Injection Opiate Use Following Hospitalization

BACKGROUND

Buprenorphine has established effectiveness for outpatient treatment of opioid use disorder. Our previously published STOP (Suboxone Transition to Opiate Program) trial showed that buprenorphine induction, stabilization, and linkage to outpatient treatment in opioid-dependent inpatients (injection and non-injection drug users) decreased illicit opioid use over 6months. The present study was a planned subgroup analysis of injection opiate users from STOP.

OBJECTIVE

To determine if inpatient buprenorphine initiation and linkage to outpatient buprenorphine reduce injection opiate users' frequency of injection opiate use (IOU).

METHODS

Inpatient injection opiate users at a safety-net hospital were randomized to buprenorphine linkage (induction, stabilization, bridge prescription, and facilitated referral to outpatient treatment) or detoxification (5-day inpatient buprenorphine taper). Conditional fixed-effects Poisson regression was used to estimate the effects of intervention on 30-day (self-report) at 1, 3, and 6months, measured using 30-day timeline follow-back. The secondary outcome was linkage effectiveness, measured as % presenting to initial outpatient buprenorphine visits after hospital discharge.

RESULTS

Analysis was limited to persons (n=62 randomized to detoxification and n=51 to linkage) with baseline IOU. There were no significant differences in age, ethnicity, or baseline IOU frequency. At follow-up, linkage patients (70.6%) were significantly more likely (p<0.001) to present to initial buprenorphine visits than detoxification patients (9.7%). However, there was no significant between group difference in the rate of IOU at 1- (IRR=0.73, p=0.32), 3- (IRR=1.20, p=0.54), or 6-month (IRR=0.73, p=0.23) follow-ups. Using person-day analysis, participants self-reported IOU on 5.8% of follow-up days in which they used prescription buprenorphine and 37.5% of non-buprenorphine days. Using a generalized estimating equation, the estimated odds of IOU was 4.57 times higher (p<0.001) on non-buprenorphine days.

CONCLUSIONS

Despite STOP's success in linking patients who inject opiates to outpatient buprenorphine, the intervention did not significantly decrease their IOU frequency. Injection opiate users will require a more intensive protocol to sustain outpatient buprenorphine treatment and decrease injection with its attendant risks.

The efficacy of behavioural activation treatment for co-occurring depression and substance use disorder (the activate study): a randomized controlled trial

BACKGROUND

Epidemiological studies suggest that compared with the general population, mood disorders are up to 4.7 times more prevalent in substance dependent samples. Comorbid substance use disorder (SUD) and depression has been associated with a more severe and protracted illness course and poorer treatment outcomes. Despite this, the development and assessment of behavioural interventions for treating depression among individuals with SUDs have received little empirical attention. Behavioural Activation Treatment for Depression (BATD-R) is an empirically supported treatment for depression that has shown some efficacy among substance users. This paper describes the study protocol of a parallel, single blind, randomised controlled trial to determine the efficacy and feasibility of a modified version of the BATD-R (Activate) in reducing symptoms of depression and substance dependence among individuals in residential rehabilitation (RR) and opioid substitution therapy (OST).

METHODS/DESIGN

A sample of approximately 200 individuals with depressive symptomatology in treatment for SUD will be recruited from RR and OST services in New South Wales, Australia. Dynamic random allocation following minimisation methodology will be used to assign participants to one of two groups. The control group will receive treatment as usual (TAU), which will be the model of care provided in accordance with standard practice at participating RR and OST services. The intervention group will receive Activate, comprising 10 individual 60-min therapy sessions with a psychologist employed on the research team, in addition to TAU. Data collection will occur at baseline (pre-intervention), and 3-months and 12-months post baseline.

DISCUSSION

The association between depression and substance dependence has been well documented, yet practical and effective treatments are scarce. The findings of the present study will contribute significantly to understanding the types of programs that are effective in treating this comorbidity.

TRIAL REGISTRATION

This trial is registered with the Australian and New Zealand Clinical Trials registry, ACTRN12613000876796 . Registered on 7 August, 2013.

The CHANGE Study: Methods and Sample Description for a Cross-Sectional Study of Heroin Cessation in New York City

The CHANGE (Cessation of Heroin: A Neighborhood Grounded Exploration) Study aimed to understand factors associated with the initiation and maintenance of sustained heroin cessation from the perspective of users themselves and specifically set out to document the correlates of natural recovery. The CHANGE Study was a case-control study conducted in New York City from 2009 to 2011. Cases were former heroin users, abstinent for 1-5 years in the past 5 years. Controls used heroin at least weekly during the past 5 years and were (1) continuous heroin users without a quit attempt of ≥2 weeks' duration or (2) relapsed heroin users who were currently using and had a quit attempt of ≥2 weeks' duration during the past 5 years. Recruitment and data collection methods are described along with limitations and a brief description of the study sample. In contrast to many studies of drug use and cessation, the CHANGE Study was designed to model success (i.e., initiation and maintenance of heroin cessation) and not failure.

Fatal opioid poisoning: a counterfactual model to estimate the preventive effect of treatment for opioid use disorder in England

AIM

A counterfactual model was used to estimate the number of fatal opioid-related poisonings prevented by public treatment services for opioid use disorder (OUD) in England between April 2008 and March 2011.

METHODS

Patient OUD treatment episode data recorded by the English National Drug Treatment Monitoring System were linked to data on opioid deaths recorded by the Office for National Statistics. The source population was the official estimate of non-medical opioid users (aged 15-64 years; approximately 260 000 each year). The target population was all individuals (aged 15-64 years) treated for OUD in the study period (n = 220 665). The outcome measure was fatal opioid-related poisoning (opioid death). The opioid death rate [per 100 person-years (PY)] and mortality rate ratios (MRR) were computed for study year, age group (15-24, 25-34, 35-64 years) and for three treatment-related states: time spent 'prior to treatment', 'during treatment' and 'after treatment'.

RESULTS

Between April 2008 and March 2011, there were 3731 opioid deaths in the study: 741 during treatment (0.20 per 100 PY; referent category); 2722 prior to treatment [0.77 per 100 PY; MRR = 3.76, 95% confidence interval (CI) = 3.18-4.44]; and 268 after treatment (0.41 per 100 PY; MRR = 1.99, 95% CI = 1.64-2.41). By counterfactual estimation, national OUD treatment services prevented an average of 880 opioid deaths each year (95% CI = 702-1084).

CONCLUSIONS

Between April 2008 and March 2011, a counterfactual model shows that the English public treatment system for opioid use disorder prevented an average of 880 deaths each year from opioid-related poisoning. Counterfactual models of mortality prevention can be used for outcome and performance monitoring of substance use disorder treatment systems.

Long-term course of opioid addiction

Opioid addiction is associated with excess mortality, morbidities, and other adverse conditions. Guided by a life-course framework, we review the literature on the long-term course of opioid addiction in terms of use trajectories, transitions, and turning points, as well as other factors that facilitate recovery from addiction. Most long-term follow-up studies are based on heroin addicts recruited from treatment settings (mostly methadone maintenance treatment), many of whom are referred by the criminal justice system. Cumulative evidence indicates that opioid addiction is a chronic disorder with frequent relapses. Longer treatment retention is associated with a greater likelihood of abstinence, whereas incarceration is negatively related to subsequent abstinence. Over the long term, the mortality rate of opioid addicts (overdose being the most common cause) is about 6 to 20 times greater than that of the general population; among those who remain alive, the prevalence of stable abstinence from opioid use is low (less than 30% after 10-30 years of observation), and many continue to use alcohol and other drugs after ceasing to use opioids. Histories of sexual or physical abuse and comorbid mental disorders are associated with the persistence of opioid use, whereas family and social support, as well as employment, facilitates recovery. Maintaining opioid abstinence for at least five years substantially increases the likelihood of future stable abstinence. Recent advances in pharmacological treatment options (buprenorphine and naltrexone) include depot formulations offering longer duration of medication; their impact on the long-term course of opioid addiction remains to be assessed.

Time to relapse following treatment for methamphetamine use: a long-term perspective on patterns and predictors

INTRODUCTION

This paper describes methamphetamine (MA) use patterns, specifically the duration of continuing abstinence ("time to relapse") for periods averaging 5 years post-discharge from treatment for MA use, and the relationship with selected user and treatment characteristics.

METHODS

A sample of 350 treatment admissions from a large county substance use disorder (SUD) treatment system was randomly selected (within gender, race/ethnicity, treatment modality strata). Retrospective self-report data are from natural history interviews (NHI) conducted approximately 3 years after treatment and a follow-up of 2-3 years later. Relapse is defined as any use of MA with time as the number of months of continuous MA abstinence after treatment discharge until relapse. This outcome was constructed from a monthly MA use timeline using NHI data. A Cox model was used to examine time to relapse and predictors.

RESULTS

Sixty-one percent of the sample relapsed to MA use within 1 year after treatment discharge and 14% during years 2-5. Significant protective factors predicting longer time to relapse included having experienced serious MA-related psychiatric/behavioral problems (hazard ratio [HR]=0.75, p=0.027), longer duration of the index treatment episode (HR=0.93, p=0.001), and participating in self-help or other treatment during the post-treatment abstinence period (HR=0.29, p<0.001); risk factors for shorter time to relapse included having a parent with alcohol and/or drug use problems (HR=1.35, p=0.020) and involvement in MA sales (HR=1.48, p=0.002).

CONCLUSIONS

Results contribute a long-term perspective on patterns of MA use following treatment and support a need for early post-treatment and long-term continuing care and relapse-prevention services.

Predictors of non-prescribed opioid use after one year of methadone treatment: an attributable-risk approach (ANRS-Methaville trial)

BACKGROUND

The effectiveness of methadone as an opioid maintenance treatment (OMT) for opioid dependence has been widely demonstrated. However many patients continue to use other opioids while on methadone treatment. Studies assessing avoidable cases of continued non-prescribed opioid use during methadone treatment are sparse.

METHODS

At 12 months of treatment (M12), 158 subjects had available data on opioid use, measured using the Opiate Treatment Index. We identified variables associated with non-prescribed opioid use at M12, using a univariate logistic regression and two multivariate models, one incorporating only pre-treatment variables, the second adding the in-treatment variables. We also calculated attributable fractions for risk factors.

RESULTS

At M12, 32.3% of the patients had used non-prescribed opioids during the previous month. A good patient-physician relationship was the most influential factor associated with not using non-prescribed opioids after one year. Living with a heroin user after one year of treatment, using cocaine during treatment and hazardous alcohol consumption at enrolment were all associated with an increased risk of non-prescribed opioid use at M12. Analysis of attributable fractions indicated that living with a heroin user at M12 accounted for 21% of patients reporting non-prescribed opioid use at M12, while the lack of a good relationship with the physician accounted for 26%.

CONCLUSIONS

The attributable risk approach suggests that continued non-prescribed opioid use by a considerable proportion of individuals could potentially be reduced by improving patient-physician relationships, enhancing care for co-dependent patients and encouraging patients to modify their social network.

Comparative patterns of cognitive performance amongst opioid maintenance patients, abstinent opioid users and non-opioid users

BACKGROUND

To compare the cognitive performances of maintenance patients (MAIN), abstinent ex-users (ABST) and healthy non-heroin using controls (CON).

METHODS

Case control study of 125 MAIN (94 subjects maintained on methadone, 31 on buprenorphine), 50 ABST and 50 CON. Neuropsychological tests measuring executive function, working memory, information processing speed, verbal learning and non-verbal learning were administered.

RESULTS

There were no differences between the cognitive profiles of those maintained on methadone or buprenorphine on any administered test. After controlling for confounders, the MAIN group had poorer performance than controls in six of the 13 administered tests, and were poorer than the ABST group in five. The MAIN group exhibited poorer performance in the Haylings Sentence Completion, Matrix Reasoning, Digit Symbol, Logical Memory (immediate and delayed recall), and the Complex Figure Test (immediate recall). There were no differences between the ABST and CON groups on any of the administered tests.

CONCLUSIONS

Poorer cognitive performance, across a range of test and domains, was seen amongst maintenance patients, regardless of their maintenance drug. This is a group that is likely might benefit from approaches for managing individuals with cognitive and behavioural difficulties arising from brain dysfunction.

Risk adjustment of heroin treatment outcomes for comparative performance assessment in England

AIMS

Variability in effectiveness of treatment for substance abuse disorder (SUD) is an important and understudied issue. This study aimed to quantify the extent of outcome variability in the English SUD treatment system after adjusting for potential confounding variables.

DESIGN

Prospective cohort study using data from the English national drug treatment outcome monitoring database.

SETTING

All 149 administrative areas delivering publicly funded SUD services in the National Health Service and non-governmental sector.

PARTICIPANTS

New adult admissions between January 2008 and October 2010 with illicit heroin-related problems in all administrative areas, with an in-treatment review conducted between 5 and 26 weeks (mean = 129.5 days; SD = 40.0) up to 30 April 2011 (n = 65 223; 75.6% of eligible clients). Individuals were divided randomly to form model developmental and internal validation samples. These were contrasted with an independent (external) sample of the same population admitted to treatment between November 2010 and April 2011 and followed to 31 October 2011 (n = 13 797; 81.4% of those eligible).

MEASUREMENTS AND ANALYSIS

The outcome measure was self-reported illicit heroin use, categorized as abstinent or deteriorated (the latter by Reliable Change Index), each risk-adjusted by person-level (demographics, clinical severity and treatment complexity) and area-level (SUD prevalence, social deprivation and severity averages) covariates by multivariable logistic regression using multiply imputed outcome and covariate data. Risk-adjusted models were assessed by information criteria and discrimination (c-index). Standardized outcome rates were compared by funnel plot with 95% and 99% control limits.

FINDINGS

Models of heroin abstinence (48.4%) and deterioration (3.2%) were comparable across the developmental and validation samples (c-index = 0.70-0.71 and 0.82-0.87), with 79.2 and 94.0%, respectively, of the 149 treatment areas falling within 95% control limits. At the 99% limit, seven areas (4.7%) achieved abstinence rates above the national average, and eight had relatively poor abstinence rates (5.4%). At the 99% control limit, one area achieved very low deterioration outcomes and two (1.3%) were worse that the average. Risk adjustment served to increase abstinence rates in good performing areas by 0.63% and reduce abstinence rates by 0.37% in poor performing areas, and by 0.12% and 0.18%, respectively, for deterioration.

CONCLUSION

There is some exceptional variability in the apparent effectiveness of the English treatment system for substance use disorders. It is important to determine the source of this variability in order to inform drug treatment delivery and its evaluation both in England and overseas.

A 25-year follow-up of patients admitted to methadone treatment for the first time: mortality and gender differences

INTRODUCTION

We conducted a follow-up study to evaluate the outcome of a heroin-dependent population 25 years after their first enrollment in methadone maintenance treatment (MMT). We assessed mortality in the sample plus actual drug use, treatment, and medical factors associated with drug dependence, focusing on possible gender differences.

METHODS

Prospective follow-up study of 214 heroin-dependent patients consecutively admitted for MMT between 1980 and 1984 in the Asturias Public Health Service. The standardized mortality ratio (SMR) and 95% confidence interval (CI) were calculated. An ad-hoc protocol on drug misuse and treatment, drug-related morbidity and Clinical Global Impression (CGI) scores were assessed in the survivors' sample.

RESULTS

Information was received on 159 subjects, 106 of whom were deceased. Men accounted for 76.2% of the study cohort. Over the 25-year follow-up period, the SMR was 22.51 (95% CI=22.37-22.64). In the survivors sample, 39.6% were still enrolled in MMT; human immunodeficiency virus (HIV) was diagnosed in 47.2% and hepatitis B/C in 81.1%; current heroin use was reported by 22.6%. There were no gender differences in mortality or HIV and hepatitis B/C status. None of the female survivors were using heroin at the 25-year follow-up compared with 31.1% of males.

CONCLUSIONS

This study confirms the high mortality of heroin addicts even after enrollment in MMT. Severity of the addiction in terms of mortality was similar in both genders. Women who survived the 25-year follow-up were more likely to have stopped using heroin than men.

Abstinence-orientated residential rehabilitation of opioid users in Denmark: do changes in national treatment policies affect treatment outcome?

AIMS

Significant changes in the Danish drug-abuse treatment system occurred from 1998 to 2008, allowing the opportunity to study their impact on outcomes for opiate dependent patients. This paper examines whether such changes are related to possible changes in abstinence rates of two cohorts of drug users.

METHODS

We compared survival curves and the month-by-month probability of abstinence between cohorts of drug abusers who were followed for one year after treatment for opioid dependence in 1998 (n = 305) and in 2008 (n = 204). Of the 1998 cohort, 192 were interviewed face-to-face and 61 were found through national drug-abuse treatment registers. Of the 2008 cohort 112 were interviewed face-to-face and 42 were found through national drug-abuse treatment registers.

RESULTS

Survival curves did not differ between the two cohorts. After controlling for age and gender, people from the 2008 cohort had a higher frequency of month-to-month rates of abstinence. A higher proportion of clients received new treatment after their index treatment in 2008. Clients from the 1998 cohort who did not receive new treatment used drugs more often than clients who did not receive treatment in 2008. At the same time, the proportion of clients who received residential rehabilitation treatment for opiate dependence increased substantially by 2008.

CONCLUSIONS

Total abstinence rates are highly consistent over time and seem to change little with changes in systems of care. However, changes in care that improve access to treatment may reduce the overall burden of opioid addiction to both individuals and society.

Sex differences amongst dependent heroin users: histories, clinical characteristics and predictors of other substance dependence

INTRODUCTION AND AIMS

To examine differences in the characteristics and histories of male and female dependent heroin users, and in the clinical characteristics associated with multiple substance dependence diagnoses.

DESIGN AND METHODS

1513 heroin dependent participants underwent an interview covering substance use and dependence, psychiatric history, child maltreatment, family background, adult violence and criminal history. Family background, demographic and clinical characteristics were analysed by sex. Ordinal regression was used to test for a relationship between number of substance dependence diagnoses and other clinical variables.

RESULTS

Women were more likely to experience most forms of child maltreatment, to first use heroin with a boyfriend or partner, to experience ongoing adult violence at the hands of a partner, and to have a poorer psychiatric history than men. Males had more prevalent lifetime substance dependence diagnoses and criminal histories and were more likely to meet the criteria for ASPD. Predictors of multiple substance dependence diagnoses for both sexes were mental health variables, antisocial behaviour, childhood sexual abuse, victim of adult violence, younger age at first cannabis use and overdose. As the number of dependence diagnoses increased, clinical and behavioural problems increased. Childhood emotional neglect was related to increasing dependence diagnoses for females but not males, whereas PTSD was a significant predictor for males but not females.

DISCUSSION AND CONCLUSIONS

Mental health problems, other substance dependence, childhood and adult trauma were common in this sample, with sex differences indicating different treatment needs and possible different pathways to heroin dependence for men and women.

Benzodiazepine use among heroin users: baseline use, current use and clinical outcome

INTRODUCTION AND AIMS

Benzodiazepine use is associated with elevated levels of harm. The current study aimed to ascertain the long-term nature of the relationship between benzodiazepine use and clinical profile among heroin users.

DESIGN AND METHODS

Longitudinal cohort, with follow-up at 3, 12, 24 and 36 months. Participants were 615 heroin users recruited for the Australian Treatment Outcome Study.

RESULTS

At baseline, current benzodiazepine users were more likely to be committing crime, had poorer psychological health and poorer physical health. Baseline benzodiazepine use was not associated with the likelihood across follow-up of heroin use (P = 0.44), committing crime (P = 0.17), poorer psychological health (P = 0.31) or poorer physical health (P = 0.48). Current benzodiazepine use was, however, associated with a greater likelihood of concurrent heroin use (OR 2.77), crime (OR 2.04), poorer psychological health (beta = -4.47) and poorer physical health (beta = -2.33).

DISCUSSION AND CONCLUSIONS

Clinicians should be aware that reductions in benzodiazepine use are associated with reductions in harm, and that baseline benzodiazepine status does not equate to poor long-term outcome.

The toxicology of homicide offenders and victims: A review

ISSUES

The toxicology of homicide offenders and victims, and homicide as a cause of death among psychoactive substance users.

APPROACH

Review of the toxicology of homicide, and homicide as a cause of death among psychoactive substance users.

KEY FINDINGS

A half or more of offenders are intoxicated by a psychoactive substance at the time of the homicide, with alcohol the most commonly reported substance. Levels of substances among victims are comparable with those seen among perpetrators. Among both offenders and victims, levels of substances far exceed population use. Among substance users, homicide specific mortality rates of substance users far exceed population rates. Reducing rates of alcohol and other drug consumption, at national and individual levels, can be expected to substantially reduce rates of, and risk for, homicide.

CONCLUSIONS AND IMPLICATIONS

Psychoactive substances are strongly associated with homicide. One of the major societal benefits that can be derived from active attempts to reduce alcohol and other drug use are reductions in homicide rates.

Comparing the dynamic course of heroin, cocaine, and methamphetamine use over 10 years

To examine dynamic changes in drug-use trajectories over time we analyzed episode types and predictors of quitting use over the 10 years following drug-use initiation for 1797 heroin, cocaine, and methamphetamine (meth) users. Most episodes reflected high use and incarceration, however these events occurred more frequently among heroin and meth users. Quitting was predicted by current treatment and self-help participation among meth (RR 2.57, 1.79-3.70; 2.57, 1.80-3.67) and cocaine (RR 2.00, 1.42-2.81; 2.10, 1.63-2.72) users, and by a history of quitting for meth users (RR 1.11, 1.06-1.17). Quitting was less likely among all users under legal supervision (RR 0.55-0.69) and among heroin (RR 0.66, 0.45-0.97) and meth users (RR 0.73, 0.60-0.89) with an early drug-use onset. Relative to cocaine or meth use, heroin use was characterized by persistent use at a high-level which was often only interrupted by incarceration. While quitting drug use can be facilitated by treatment and/or self-help participation, few people had these experiences in the 10 years following first use.

Injecting and Noninjecting Heroin Administration: Transitions and Treatment Outcomes across 36 Months

To examine long-term stability in route of administration and treatment outcomes for noninjecting (NIHU) and injecting (IHU) heroin users, a cohort of 429 heroin users were followed over 36 months. Across follow-up, 35.3% of NIHU injected heroin and a transition to primary heroin injecting was made by 8.5%. Amongst IHU, 11.1% smoked heroin and a transition to primary heroin smoking was made by 2.3%. While NIHU were less likely to be in treatment at 36 months, there were no differences in overall treatment exposure. At 36 months, there were no differences in heroin use, polydrug use, crime, physical health, or psychopathology. NIHU were, however, less likely to be injecting and to have injection-related health problems. It is concluded that there is a substantial risk of injecting occurring amongst NIHU and that route of administration does not differentially predict long-term treatment response.

Should heroin be prescribed to heroin misusers? No

Some heroin addicts are very difficult to treat. Jürgen Rehm and Benedikt Fischer believe that maintenance with heroin is the way forward for this group, but Neil McKeganey argues that it is treating the effects of misuse not the addiction