Reductions in heroin use are not associated with increases in other drug use: 2-year findings from the Australian Treatment Outcome Study

Associations Between Buprenorphine\Naloxone and Methadone Treatment and non-Opioid Substance Use in Prescription-Type Opioid Use Disorder: Secondary Analyses From the OPTIMA Study: Associations entre le traitement avec la buprénorphine/naloxone et avec la méthadone et l'utilisation de substances non opioïdes dans le trouble lié à l'usage d'opioïdes de type sur ordonnance : analyses secondaires de l'étude OPTIMA

OBJECTIVES

There is limited evidence on how opioid agonist treatment (OAT) may affect psychoactive non-opioid substance use in prescription-type opioid use disorder (POUD) and whether this effect might explain OAT outcomes. We aimed to assess the effect of methadone on non-opioid substance use compared to buprenorphine/naloxone (BUP/NX), to explore whether non-opioid substance use is associated with opioid use and retention in treatment, and to test non-opioid use as a moderator of associations between methadone with retention in OAT and opioid use compared to BUP/NX.

METHODS

This is a secondary analysis of data from the OPTIMA trial, an open-label, pragmatic, parallel, two-arm, pan-Canadian, multicentre, randomized-controlled trial to compare standard methadone model of care and flexible take-home dosing BUP/NX for POUD treatment. We studied the effect of methadone and BUP/NX on non-opioid substance use evaluated by urine drug screen (UDS) and by classes of non-opioid substances (i.e., tetrahydrocannabinol [THC], benzodiazepines, stimulants) (weeks 2-24) using adjusted generalized estimation equation (GEE). We studied the association between non-opioid substance-positive UDS and opioid-positive UDS and retention in treatment, using adjusted GEE and logistic regressions.

RESULTS

Overall, methadone was not associated with non-opioid substance-positive UDS compared to BUP/NX (OR: 0.78; 95%CI, 0.41 to 1.48). When non-opioid substances were studied separately, methadone was associated with lower odds of benzodiazepine-positive UDS (OR: 0.63; 95% CI: 0.40 to 0.98) and THC-positive UDS (OR: 0.47; 95% CI: 0.28 to 0.77), but not with different odds of stimulant-positive UDS (OR: 1.29; 95% CI: 0.78 to 2.16) compared to BUP/NX. Substance-positive UDS, overall and separate classes, were not associated with opioid-positive UDS or retention in treatment.

CONCLUSION

Methadone did not show a significant effect on overall non-opioid substance use in POUD compared to BUP/NX treatment but was associated with lower odds of benzodiazepine and THC use in particular. Non-opioid substance use did not predict OAT outcomes. Further research is needed to ascertain whether specific patterns of polysubstance use (quantity and frequency) may affect treatment outcomes.

Virtual opioid agonist treatment: Alberta's virtual opioid dependency program and outcomes

Background

Virtually delivered healthcare (telehealth, telemedicine) has the potential to reduce gaps in access to opioid agonist therapy (OAT). Barriers to accessing OAT such as lack of transportation, in-person induction requirements, employment demands and limited childcare options reduce treatment opportunities for clients. A completely virtual model of care has been developed in Alberta, Canada. This paper introduces the unique virtual clinic model and describes outcomes from that model.

Methods

A retrospective chart review was conducted using datasets within existing electronic health records and databases from Alberta’s Virtual Opioid Dependency Program (VODP). Outcome data were extracted at admission to ongoing care by Case Management within the VODP and at 3, 6 and 12 months for the duration of treatment. Utilization trends over three years were analyzed, including admissions, discharges and active client information. Data regarding clinical outcomes for clients engaged in ongoing care with the VODP were aggregated for analysis over four time periods, including treatment retention rates at 6 and 12 months.

Results

A total of 440 client records were included in the study sample. Descriptive analysis showed rapid growth in utilization over three fiscal years. Despite rapid growth in utilization, median wait days for treatment decreased from 6 to 0 days with the initiation of a Same Day Start service to support low barrier immediate access to treatment. Treatment retention rates for clients in ongoing care were comparable to published reports, with 90% of the study sample remaining in treatment over 6 months, and 58% showing retention over 12 months. Clients reported high levels of satisfaction (90%) and outcomes reflected reductions in drug use and overdose as well as improved social functioning.

Conclusions

The VODP model demonstrated high levels of client satisfaction, rapid growth in utilization and positive preliminary clinical outcomes. Entirely virtual delivery of opioid agonist therapy is a promising option to facilitate access to evidence based treatment for opioid use disorder (OUD) in the context of a fentanyl overdose crisis, particularly for individuals living in rural or underserved areas.

A systematic review of addiction substitution in recovery: Clinical lore or empirically-based?

This systematic review synthesized the literature examining addiction substitution during recovery from substance use or behavioral addictions. A total of 96 studies were included with sample sizes ranging from 6 to 14,885. The most common recovery addictions were opioids (30.21%), followed by cannabis (20.83%), unspecified use (17.71%), nicotine (12.50%), alcohol (12.50%), cocaine (4.17%), and gambling (2.08%). Statistical results were provided by 70.83% of the studies. Of these, 17.65% found support for addiction substitution, whereas 52.94% found support for concurrent recovery. A total of 19.12% found no statistical changes and 10.29% found both significant increases and decreases. The remaining 29.17% of studies provided descriptive data, without statistical tests. Predictors of addiction substitution were provided by 22.92% of the studies and 11.46% included information on impact of addiction substitution on treatment outcomes. Overall, male gender, younger age, greater substance use severity, and presence of mental health disorders were associated with addiction substitution. Addiction substitution was associated with poorer treatment outcomes. A limitation of the present systematic review is the use of significance counting for the quantitative synthesis. More research examining changes in addiction during recovery would aid in the development of more effective treatments for addictive disorders and prevent addiction substitution.

Substitute Addictions in Persons with Substance Use Disorders: A Scoping Review

Substitute addictions, addictive behaviors that sequentially replace each other's functions, have implications for recovery trajectories but remain poorly understood. We sought to scope the extent, range, and characteristics of research on substitute addictions in persons with substance use disorders. Method: Using Arksey and O'Malley's framework for scoping reviews, a systematic search was conducted to identify publications that referenced substitute addictions up to April 2018. Study characteristics were extracted and summarized to provide an overview of the extant literature. Results: The 63 included studies show that substitute addictions are terminologically and conceptually ambiguous. Much of the available literature is concentrated in developed contexts - and in particular the United States of America. While presentations varied, at least two sub-types of substitute addictions appeared: long-term replacement and temporary replacement. Existing theories suggest a multifactorial etiology. Conclusions: The findings suggest a strong need for: increased awareness of substitute addictions and its potential consequences for recovery; interventions that structure prevention and pre-, during-, and post-treatment interactions as well as future research to explore its nature and dynamics drawing on multiple methods.

Changes in substance use in relation to opioid agonist therapy among people who use drugs in a Canadian setting

BACKGROUND

Although previous studies have shown that opioid agonist therapy (OAT) is linked to reductions in illicit opioid use, less is known about how OAT impacts the use of other psychoactive substances. We aimed to examine the changes in use of different substances by comparing patterns before and after initiating OAT.

METHODS

Data for this study was derived from three ongoing prospective cohorts involving people who use drugs in Vancouver, Canada from 1996 to 2018. We assessed use patterns for heroin, illicit prescription opioid, cocaine, crack cocaine, crystal methamphetamine, cannabis, daily alcohol use, and benzodiazepines. Segmented regression was conducted to compare the trends of substance use between pre-treatment and post-treatment periods.

RESULTS

The study included 1107 participants. After OAT engagement, we observed an immediate decline in the proportion as well as a decreasing trend for heroin (Adjusted Odds Ratio (AOR): 0.80, 95% confidence interval (CI): 0.77, 0.83), illicit prescription opioid (AOR: 0.87, 95% CI: 0.83, 0.90), and benzodiazepines (AOR: 0.73, 95 % CI: 0.67, 0.80). There was no significant difference comparing the pre-treatment and post-treatment trends for cocaine, crack cocaine, crystal methamphetamine, and cannabis. However, higher growth slope was noted during the post-treatment period for daily alcohol use (P = 0.016).

CONCLUSIONS

We observed significant reduction in illicit opioids use following OAT initiation, but not for stimulant and cannabis. The increasing problematic use of alcohol may pose challenges to the safety and effectiveness of OAT. Development of comprehensive and tailored treatment strategies is needed for poly-substance users accessing OAT.

An Inverse Relationship Between Alcohol and Heroin Use in Heroin Users Post Detoxification

Background

Given that fewer than 50% of countries provide Opioid Agonist Maintenance Therapies (OAMT), it is important to assess whether other substances act as a substitute for heroin in recovering heroin users who receive detoxification models of treatment. There is a dearth of prospective studies from low-and-middle-income countries evaluating these patterns of substance use.

Methods

300 heroin users from the Gauteng province of South Africa were assessed on entry into inpatient detoxification and then followed-up 3 and 9 months after leaving treatment. Treatment consisted of 1 week of detoxification followed by 6-8 weeks of psychosocial therapy. We measured the overall changes in the prevalence of heroin, alcohol and other drug use at baseline and postrehabilitation. Comparison of these outcomes at enrolment, 3 months and 9 months was performed by a Generalised Estimating Equation (GEE) with the outcome as the dependent variable, observation point as the independent variable, and participant as the repeated measure. Injecting status and treatment completion were included as covariates. We also measured the individual pathways between heroin and alcohol use in the 210 participants that were seen at all three timepoints.

Results

Of the original cohort, 252 (84.0%) were re-interviewed at 3 months and 225 (75.0%) at 9 months. From baseline to 3 months, the proportion of past month heroin users decreased significantly to 65.5%; however, during this time, the proportion of past month alcohol users increased from 16.3% to 55.2% (p<0.0001). When assessing the pathways between heroin and alcohol use at an individual level, 55.4% (n-97) of those who were past month alcohol abstinent prior to rehabilitation were using alcohol at 3 months. From 3 to 9 months the proportion of heroin users increased to 72.4% (p<0.0001), and during this time, the proportion of alcohol users decreased.

Conclusion

After detoxification, a significant reduction in heroin use was observed with a concomitant increase in alcohol consumption. Under these circumstances, alcohol may have acted as a substitute for heroin in the short term. The initial reduction in heroin use 3 months postrehabilitation was followed by increased consumption 6 months later. This observation supports the need for interventions to prevent, monitor and treat high levels of alcohol use in heroin users post detoxification. The provision of OAMT is a necessary consideration to address both the risk of increased alcohol intake as well as the decline in heroin abstinence rates.

A prospective observational study of heroin users in Johannesburg, South Africa: Assessing psychiatric comorbidities and treatment outcomes

BACKGROUND

Despite the rise in heroin use in sub Saharan-Africa opioid agonist maintenance treatment (OAMT) is still not state-funded in South Africa and many other African countries. In South Africa there has been little data published on the profile of heroin users and the outcomes of treatment for those who attend public treatment services.

METHODS

300 heroin users from two state-funded rehabilitation centres in Johannesburg were studied at entry into rehabilitation and 3-months after treatment. Treatment consisted of inpatient detoxification and inpatient psychosocial rehabilitation. Structured interviews measured changes in drug use, psychopathology and criminality post rehabilitation.

RESULTS

Most (65.7%) smoked heroin in combination with cannabis while 29.7% were injecting users. Almost half the sample (49.3%) had at least one mental illness. Of the 252 (84%) participants seen at 3-month follow-up, 6.3% were abstinent of all substances (excluding tobacco), 65.5% had continued heroin use (CHU) and the balance used other substances. At follow-up there were significant decreases in heroin use (p<0.0001) and criminality (p<0.0001). There were however significant increases in alcohol use (p<0.0001), crystalmetamphetamine use (p=0.032) and the prevalence of current episode of major depression (p<0.0001). Just 11.9% received formal psychosocial treatment after leaving rehabilitation. None were on OAMT and only three participants were on psychotropic medication. None were tested for Hepatitis C during the study period and the majority (53%) did not know their HIV status.

CONCLUSION

There are significant gaps in current treatment services for heroin users in South Africa. Retention in treatment and assessment and management of psychiatric and non-psychiatric comorbidities is low. Services need to be more integrated and should also include the provision of OAMT.

Change in alcohol and other drug use during five years of continuous opioid substitution treatment

BACKGROUND

English national prospective, observational cohort study of patients continuously enrolled for five years in opioid substitution treatment (OST) with oral methadone and sublingual buprenorphine. This is a secondary outcome analysis of change in use of alcohol and other drug use (AOD) following identification of heroin use trajectories during OST.

METHODS

All adults admitted to community OST in 2008/09 and enrolled to 2013/14 (n = 7717). Data from 11 sequential, six-monthly clinical reviews were used to identify heroin and AOD use trajectories by multi-level Latent Class Growth Analysis. OST outcome in the sixth and seventh year was 'successful completion and no re-presentation' (SCNR) to structured treatment and was assessed using multi-level logistic regression.

RESULTS

With 'rapid decreasing' heroin use trajectory as referent, 'continued high-level' heroin use predicted 'continued high-level' crack cocaine use (relative risk ratio [RRR] 58.7; 95% confidence interval [CI] 34.2-100.5),'continued high-level' alcohol use (RRR 1.2; 95% CI 1.0-1.5), 'increasing' unspecified drug use (RRR 1.7; 95% CI 1.4-2.1) and less 'high and increasing' cannabis use (RRR 0.5; 95% CI 0.4-0.6). 'Increasing' crack use was negatively associated with SCNR outcome for the 'decreasing then increasing' and 'gradual decreasing' heroin use groups (adjusted odds ratio [AOR] 0.5; 95% CI 0.3-0.9 and AOR 0.2; 95% CI 0.1-0.7, respectively).

CONCLUSIONS

Continued high-level heroin use non-response during long-term OST is associated with high-level crack cocaine and alcohol use, increasing unspecified drug use, but less high and increasing cannabis use. Increasing use of crack cocaine is negatively associated with the likelihood that long-term OST is completed successfully.

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.

Patterns and correlates of alcohol use amongst heroin users: 11-year follow-up of the Australian Treatment Outcome Study cohort

INTRODUCTION

The study aimed to determine long-term alcohol use patterns and correlates amongst heroin users.

METHODS

Longitudinal cohort. 11-year post-baseline follow-up of the Australian Treatment Outcome Study cohort.

RESULTS

At 11-year follow-up, 431 (70%) participants were interviewed. Alcohol was used in the preceding month by 56%, with 27% reporting daily use and 11% heavy daily drinking. Alcohol use patterns showed remarkable consistency across waves, with the proportion who drank in the preceding month ranging between 49 and 56%, with no significant trend across time. Daily drinking ranged between 20 and 27%, and heavy daily drinking between 7 and 12%. Both declined slightly from baseline to 3-year follow-up, but by 11 years were at levels similar to baseline. Compared to female referents, males were more likely to drink (OR 1.6, CI 1.3-2.1, p < .05), to drink daily (OR 1.8, CI 1.4-2.4, p < .05) and to drink heavily (OR 1.7, 1.1-2.5, p < .05). Compared to those not in enrolled in a drug treatment programme, those enrolled were significantly less likely to drink (OR 0.7, CI 0.5-0.8, p < .05) and to drink daily (OR 0.6, 0.5-0.8, p < .05). Compared to those who did not drink heavily, heavy drinking was associated with a higher likelihood of recent overdose (OR 1.6, CI 1.0-2.4, p < .05), of criminality (OR 1.9, 1.3-2.7, p < .001), and with lower SF12 physical (mean difference -3.0, CI -4.7 to -1.4, p < .001) and mental (-2.4, CI -4.3 to -0.5, p < .001) health scores.

CONCLUSIONS

There were consistently high levels of both abstinence and regular drinking, with drinking patterns staying relatively stable across the decade. From the clinical perspective, the high rates of heavy drinking are of particular relevance, given the observed associations with a poorer clinical profile.

Marijuana use and achievement of abstinence from alcohol and other drugs among people with substance dependence: a prospective cohort study

BACKGROUND

Many with alcohol and other drug dependence have concurrent marijuana use, yet it is not clear how to address it during addiction treatment. This is partially due to the lack of clarity about whether marijuana use impacts one's ability to achieve abstinence from the target of addiction treatment. We examined the association between marijuana use and abstinence from other substances among individuals with substance dependence.

METHODS

A secondary analysis of the Addiction Health Evaluation And Disease management study, a randomized trial testing the effectiveness of chronic disease management. Individuals met criteria for drug or alcohol dependence and reported recent drug (i.e. opioid or stimulant) or heavy alcohol use. Recruitment occurred largely at an inpatient detoxification unit, and all participants were referred to primary medical care. The association between marijuana use and later abstinence from drug and heavy alcohol use was assessed using longitudinal multivariable models.

RESULTS

Of 563 study participants, 98% completed at least one follow-up assessment and 535 (95%) had at least one pair of consecutive assessments and were included. In adjusted analyses, marijuana use was associated with a 27% reduction in the odds of abstinence from drug and heavy alcohol use (adjusted odds ratio 0.73 [95% CI, 0.56-0.97], P=0.03).

CONCLUSIONS

Marijuana use among individuals with alcohol or other drug dependence is associated with a lower odds of achieving abstinence from drug and heavy alcohol use. These findings add evidence that suggests concomitant marijuana use among patients with addiction to other drugs merits attention from clinicians.

The association of childhood physical abuse with the onset and extent of drug use among regular injecting drug users

AIMS

To determine whether childhood physical abuse (CPA) histories were associated with age of onset of psychoactive substance use and injecting, and the extent of polydrug use among injecting drug users (IDU).

DESIGN

Cross-sectional.

SETTING

Sydney, Australia.

PARTICIPANTS AND MEASUREMENTS

A total of 300 IDU were administered a structured interview examining the prevalence and severity of CPA and drug use histories.

FINDINGS

Of the participants, 40.3% had experienced severe abuse (SA), 34.0% mild-moderate abuse (MMA) and 25.7% no abuse history (NA). After controlling for other variables, a history of severe CPA was a significant independent correlate of an earlier age at first alcohol intoxication compared to both the NA (β = -0.23, P < 0.01) and MMA (β = 0.20, P < 0.01) groups. Severe CPA was also a significant independent correlate of an earlier age at first illicit drug use compared to both the NA (β = -0.16, P < 0.05) and MMA (β = -0.15, P < 0.05) groups. In contrast, CPA histories were not independently associated with the onset of injecting drug use. After controlling for potential confounders, both the MMA (β = 0.28, P < 0.001) and SA (β = 0.27, P < 0.001) groups were associated with more extensive life-time polydrug use, but did not differ from each other (P = 0.82). After controlling for potential confounders, both MMA (β = 0.20, P < 0.01) and SA (β = 0.33, P < 0.001) group membership were associated with more extensive recent polydrug use but, again, did not differ significantly from each other (P = 0.08).

CONCLUSIONS

Severe childhood physical abuse severity is associated with an earlier initiation into drug use. Any level of abuse is associated with more extensive life-time and recent polydrug use.

Overlooked and underestimated? Problematic alcohol use in clients recovering from drug dependence

AIMS

Despite recognition of the harms related to alcohol misuse and its potential to interfere substantially with sustained recovery from drug dependency, research evaluating drug treatment outcomes has not addressed the issue comprehensively. It has been overlooked possibly because treatment research has been framed according to the primary drug of choice, rather than investigating the interactions between different combinations of drugs and/or alcohol use. This paper reports on a systematic review investigating whether concurrent alcohol use could impede recovery from illicit drug use in two potential ways: first, alcohol could become a substitute addiction and/or secondly, alcohol misuse post-treatment may place an individual at risk for relapse to their primary drug problem.

METHOD

A systematic search of four relevant databases was undertaken to identify peer-reviewed, quantitative drug treatment outcome studies that reported alcohol use pre-, post-treatment and follow-up.

RESULTS

The search revealed 567 papers, of which 13 were assessed as fulfilling the key inclusion criteria.The review indicated inconsistent and therefore inconclusive support for the substitution hypothesis. However, the data revealed consistent support for the hypothesis that alcohol use increases relapse to drug use.

CONCLUSIONS

(i) The potential negative impact of alcohol misuse on drug treatment outcomes remains under-researched and overlooked; (ii) alcohol consumption post-drug treatment may increase the likelihood that an individual will relapse to their primary drug; (ii) existing evidence regarding the substitution hypothesis is inconclusive, although there was an indication that a subgroup of participants will be vulnerable to alcohol becoming the primary addiction instead of drugs. We argue that future drug treatment outcome studies need to include detailed analysis of the influence of alcohol use pre- and post-drug treatment.

Attitudes of regular injecting drug users towards the legal status of the major illicit drugs

INTRODUCTION AND AIMS

The study aimed to determine injecting drug users' (IDU) attitudes, and correlates of attitudes, towards continued prohibition, decriminalisation or legalisation of the major illicit drugs.

DESIGN AND METHODS

This study used structured interview with 300 IDUs who had injected on at least a weekly basis over the preceding 12 months.

RESULTS

Methamphetamine was rated the most harmful of the five illicit substances and cannabis the lowest. By far the highest level of support for legislative change was for cannabis, with only 8.7% supporting continued prohibition. While there was majority support for change to the legal status of heroin, the modal position was for decriminalisation. Support for changing the status of the three illicit psychostimulants was low, with the majority believing that methamphetamine (63.3%), cocaine (53.3%) and 3,4-methylenedioxy-N-methylamphetamine (53.3%) should remain illegal. Demographic characteristics were largely unrelated to attitudes. Lower levels of perceived harm were associated with increased likelihood of support for legalisation of all substances. Recent use was positively related to support for both decriminalisation and legality of heroin, but was not associated with views on other substances. Higher lifetime polydrug use was associated with support for the legalisation of heroin, methamphetamine, cocaine and 3,4-methylenedioxy-N-methylamphetamine.

DISCUSSION AND CONCLUSIONS

IDUs expressed nuanced views on different substances. In policy debates, care should be taken not to speak for IDUs by imputing their beliefs. It is clear that the fact that a group uses illegal drugs does not necessarily imply that they support changes to their legal status.

Pathways to heroin dependence: time to re-appraise self-medication

The self-medication hypothesis emphasizes the role of distressing affect as the primary motivator for the compulsive use that leads to substance dependence. The model also postulates that there will be psychopharmacological specificity between symptom presentation and the primary drug of dependence. In this review, the self-medication hypothesis is examined in relation to the development and chronicity of heroin dependence. It is argued that if self-medication has a role in engendering and extending substance dependence, it should be apparent in the use of a drug that carries such overwhelming personal risk. The psychopathology seen among adult users is certainly consistent with the model. More importantly, however, are the extraordinarily high levels of childhood trauma and psychopathology that occur typically well before the initiation of heroin use. In contrast, the postulate of drug specificity appears less supported by the polydrug use patterns typical of heroin users, and does not appear to be a necessary corollary of the model.

Impact of an 18-month, NHS-based, treatment exposure for heroin dependence: results from the London Area Treat 2000 Study

We set out to examine the impact of treatment for heroin dependence on drug use, injecting behavior, health problems, criminality, and physical and mental health over 18 months among heroin-dependent Londoners. A total of 100 heroin users were recruited for this longitudinal prospective cohort study with repeated measures (T0 as baseline, T1 after 9 months, and T2 after 18 months). The psychiatric evaluation and assessment of drug abuse levels were determined by the CIDI and the EuropASI. Additional evaluations included the WHO-DAS II for disability assessment and the UCLA-SSI for social support. The number of days of heroin use in the 30 days previous to each single assessment significantly reduced over time (p < .001). Similar reduction levels were observed for cocaine (p < .05), benzodiazepines (p < .001), and polydrug abuse (p < .001), but not for cannabis and alcohol. The number of injecting occasions reduced in parallel, with increase in days in work and reduction of money spent for drug acquisition activities and money obtained from criminal/illegal activities. The number of subjects experiencing suicidal ideation reduced over time (p < .05). In line with previous suggestions, significant reductions in drug use, criminality, psychopathology, and injecting behavior following treatment exposure for heroin dependence were observed. It is, however, of concern that alcohol and cannabis misuse levels remained unchanged.

Urine analysis of 3,4-methylenedioxypyrovalerone in opioid-dependent patients by gas chromatography-mass spectrometry

A gas chromatography-mass spectrometry (GCMS) procedure was developed for the quantitative analysis of the new designer drug methylenedioxypyrovalerone (MDPV) in urine together with the common stimulants amphetamine, methamphetamine, and methylenedioxymethamphetamine (MDMA). The procedure involved electron ionization (EI) GCMS in the selected ion monitoring (SIM) mode after liquid-liquid extraction with toluene and derivatization with heptafluorobutyric acid anhydride. All MDPV findings were confirmed by positive chemical ionization GCMS in SIM mode. Positive chemical ionization-GCMS allowed the protonated molecule M+H+ m/z 276 to be used as a target ion with 3 abundant fragments as qualifier ions. By electron ionization-GCMS, the limit of quantification (LOQ) for MDPV was 0.02 mg/L; and for amphetamine, methamphetamine, and MDMA, the LOQ was 0.05 mg/L. The method was applied to monitoring urine samples from opioid-dependent patients undergoing opioid substitution treatment. Nine of the 34 urine samples (26%) analyzed were MDPV positive by the GCMS procedure. The positive samples were obtained from 2 female and 7 male patients with a mean age of 31 years. The median (range) MDPV concentration was 0.16 mg/L (0.04-3.9 mg/L) based on the 7 samples for which a numeric value was obtained, whereas the concentration was below the LOQ but above the limit of detection in 2 samples. The method revealed amphetamine in approximately 40% of the cases, and there was no statistical difference between the MDPV-positive and MDPV-negative groups. Urine amphetamine concentrations were on average 10 times higher than those of MDPV. The opioid-dependent patients used MDPV mainly as a substitute for amphetamine, judging from the laboratory findings of this study and the information from our patients.

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.

Substitution and complementarity in the face of alcohol-specific policy interventions

AIM

Policy responses to the growing burden of alcohol-related disease fail to consider the interrelated nature of substance misuse and the potential for complex interactions in response to alcohol-specific interventions. This paper considers possible aggregate level responses to the alcohol policy and whether alcohol policy can be expected to reduce overall harm.

METHODS

A review and discussion of the relevant literature was conducted.

RESULTS

Evidence indicates that those at greatest risk consume stronger alcoholic beverages more frequently, that they are likely to complement their consumption with a range of intoxicants and that they are more likely to substitute alcohol with other substances.

CONCLUSIONS

Policies aimed at reducing alcohol consumption can be successful. However, evidence suggests a significant minority of consumers are likely to substitute or complement consumption with a range of intoxicants suggesting that policy is unlikely to reduce all-cause mortality and morbidity. Further research into the nature of substitution and complementarity is required.

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.

Daily marijuana users with past alcohol problems increase alcohol consumption during marijuana abstinence

Drug abuse treatment programs typically recommend complete abstinence because of a fear that clients who stop use of one drug will substitute another. A within-subjects study investigated whether consumption of alcohol and other substances changes during marijuana abstinence. Twenty-eight daily marijuana users who were not trying to stop or reduce their marijuana consumption completed an 8-day baseline period in which they used marijuana and other drugs as usual, a 13-day marijuana abstinence period, and a 7-day return-to-baseline period. Participants provided self-report of substance use daily and submitted urine samples twice weekly to verify marijuana abstinence. A diagnosis of past alcohol abuse or dependence significantly moderated the alcohol increase from baseline to marijuana abstinence (p<0.01), such that individuals with this diagnosis significantly increased alcohol use (52% increase) but those without this history did not (3% increase). Increases in marijuana withdrawal discomfort scores and alcohol craving scores from baseline to marijuana abstinence significantly and positively correlated with increases in alcohol use. Increases in cigarettes, caffeine, and non-marijuana illicit drugs did not occur. This study provides empirical validation of drug substitution in a subgroup of daily marijuana users, but results need to be replicated in individuals who seek treatment for marijuana problems.

Gender and comorbidity among individuals with opioid use disorders in the NESARC study

This study examines gender differences in the association of lifetime mental and substance use disorders among individuals with opioid use disorders in the United States. The sample (N=578) is from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), which is a representative household survey. Bivariate analyses and logistic regression modeling were conducted. About 70% of the sample had a lifetime non-substance use Axis I disorder; women were about twice as likely as men to have either a mood or anxiety disorder. About half of the sample had a personality disorder, with women more likely to have paranoid disorder and men more likely to have antisocial personality disorder. Individuals with a lifetime mental disorder were about three times more likely than others to be dependent on other substances, independent of gender. The study demonstrated an inverse relationship between lifetime mental and other substance use disorders, with women having significantly higher odds for several of the mental disorders and men having greater odds of other substance use disorders.

Changes in the use of medical services and prescription drugs among heroin users over two years

The study aimed to determine patterns of use of medical services and prescriptions for pharmaceuticals among 438 heroin users interviewed for the Australian Treatment Outcome Study (ATOS) at baseline, 12 and 24 months. Drug use declined markedly, and there were significant improvements in health. There were declines in the proportion of participants who had attended a general practitioner (GP) (baseline: 60%, 12 months: 53%, 24 months: 52%), who had an ambulance attendance (11%, 7%, 5%), and who were treated in an accident and emergency department (11%, 6%, 5%). While there was no decrease in the proportion who obtained a prescription (47%, 45%, 46%), there was a decrease in the mean number of reported prescriptions obtained (2.3, 1.0, 0.9). There were also differences across follow-up in the reported types of medications obtained, with a significant decrease in the proportion obtaining psychotropic medications (38%, 21%, 19%). In particular, there were large declines in the proportion who reported benzodiazepines (30%, 12%, 10%) or narcotic analgesics (8%, 3%, 4%) on prescription. While ATOS participants continued to be frequent users of health services, the cohort reported reduced levels of drug-seeking and risk commensurate with their reductions in drug use.

Polydrug use and implications for longitudinal research: ten-year trajectories for heroin, cocaine, and methamphetamine users

A typical approach to categorizing substance users for epidemiologic purposes or to identify substance use problems at treatment admission is by indicating the primary substance used and/or for which treatment is sought. But does such singular focus on the primary drug limit the validity of conclusions from longitudinal analysis of drug use patterns over time? This analysis combined data from five longitudinal studies conducted in California and examined 10-year patterns of heroin, cocaine, methamphetamine (meth), marijuana, and alcohol use for primary users of heroin (n=629), cocaine (n=694), and meth (n=474). Results suggest relatively low levels of use of non-primary heroin, cocaine, and meth, but moderate levels of alcohol and marijuana use. Growth models showed declining primary drug levels for heroin and meth users and relatively consistent levels over 10 years for cocaine users, while levels of non-primary drugs remained at consistently low levels or declined in tandem with the primary drug. Results indicate that group descriptions of primary heroin, cocaine, or meth use trajectories over time may present valid information about drug use patterns in general.

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

AIMS

To determine patterns of past month, 12 month and sustained 36 month heroin abstinence.

METHODS

As part of a longitudinal cohort study, 429 heroin users re-interviewed at 36 month follow-up for the Australian Treatment Outcome Study (ATOS).

RESULTS

The proportion who had sustained heroin abstinence since baseline declined from 14% at 12 months to 8% at 36 months. The proportion who reported abstinence over the preceding 12 months, however, increased significantly from 14% at 12 months to 40% at 36 months. There were no significant gender differences in the proportions reporting sustained 36 month abstinence. Females, however, were significantly more likely to have maintained abstinence over the 12 months preceding 36 month follow-up. Independent predictors of sustained abstinence over 36 months were fewer treatment episodes since baseline, not committing crime at baseline and higher levels of global psychological distress.

CONCLUSIONS

Despite a decline in the proportion who had maintained complete heroin abstinence over 36 months, there were substantial increases in 12 month abstinence patterns. The results illustrate the importance of stable treatment retention.

The Australian Treatment Outcome Study (ATOS): what have we learnt about treatment for heroin dependence?

Opioids make the single largest contribution to illicit drug-related mortality and morbidity worldwide In this paper we reflect upon what has been learnt regarding treatment outcome and the natural history of heroin use from the Australian Treatment Outcome Study (ATOS). We focus on what we knew prior to ATOS, what ATOS revealed that is novel, and the implications for research, practice and policy. ATOS provided strong evidence for sustained improvement attributable to treatment across the three years of the study. It is argued that treatment for heroin dependence is money well spent, and leads to clear and sustained benefits to both heroin users and society.

Patterns and correlates of attempted suicide by heroin users over a 3-year period: findings from the Australian treatment outcome study

In order to determine patterns and correlates of attempted suicide amongst heroin users across 3 years, a cohort of 387 heroin users (134 entering maintenance treatment, 134 entering detoxification, 81 entering residential rehabilitation and 38 not entering treatment) were interviewed about suicide attempts at baseline, 12, 24 and 36 months. Across the follow-up period, 11.6% attempted suicide. There were declines in the proportion who attempted suicide each year amongst both males and females and significant declines in Major Depression, suicidal ideation and current suicide plans. Despite this, levels of attempted suicide, suicidal ideation and Major Depression in the cohort remained higher than in the general population. Those who had made a previous suicide attempt were five times more likely to make an attempt across follow-up and there was a strong association between an attempt in any 1 year and increased probability of an attempt in the subsequent year. A quarter of those who reported suicidal ideation at baseline made an attempt across follow-up. At each interview point, current suicidal ideation was strongly associated with increased risk of a suicide attempt in the following year. Independent predictors of a suicide attempt across follow-up were a lifetime suicide history, baseline suicidal ideation, social isolation and the extent of baseline polydrug use. Given the strong predictive value of suicidal ideation and previous attempts, regular brief screening would appear warranted to identify those at greatest risk.

A follow-up study of heroin addicts (VEdeTTE2): study design and protocol

Background

In Italy, a large cohort study (VEdeTTE1) was conducted between 1998–2001 to evaluate the effectiveness of treatments in reducing mortality and increasing treatment retention among heroin addicts. The follow-up of this cohort (VEdeTTE2) was designed to evaluate the effectiveness of treatments on long-term outcomes, such as rehabilitation and social re-integration. The purpose of this paper is to describe the protocol of the VEdeTTE2 study, and to present the results of the pilot study carried out to assess the feasibility of the study and to improve study procedures.

Methods

The source population for the VEdeTTE2 study was the VEdeTTE1 cohort, from which a sample of 2,200 patients, traced two or more years after enrolment in the cohort, were asked to participate. An interview investigates drug use; overdose; family and social re-integration. Illegal activity are investigated separately in a questionnaire completed by the patient. Patients are also asked to provide a hair sample to test for heroin and cocaine use. Information on treatments and HIV, HBV and HCV morbidity are obtained from clinical records. A pilot phase was planned and carried out on 60 patients.

Results

The results of the pilot phase pointed out the validity of the procedures designed to limit attrition: the number of traced subjects was satisfactory (88%). Moreover, the pilot phase was very useful in identifying possible causes of delays and attrition, and flaws in the instruments. Improvements to the procedures and the instruments were subsequently implemented. Sensitivity of the biological test was quite good for heroin (78%) but lower for cocaine (42.3%), highlighting the need to obtain a hair sample from all patients.

Conclusion

In drug addiction research, studies investigating health status and social re-integration of subjects at long-term follow-up are lacking. The VEdeTTE2 study aims to investigate these outcomes at long-term follow-up. Results of the pilot phase underline the importance of the pilot phase when planning a follow-up study.