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Turner S, Allen VM, Graves L, Tanguay R, Green CR, Cook JL. Guideline No. 443a: Opioid Use Throughout Women's Lifespan: Fertility, Contraception, Chronic Pain, and Menopause. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102143. [PMID: 37977720 DOI: 10.1016/j.jogc.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
OBJECTIVE To provide health care providers with the best evidence on opioid use and women's health. Areas of focus include general patterns of opioid use and safety of use; care of women who use opioids; stigma, screening, brief intervention, and referral to treatment; hormonal regulation; reproductive health, including contraception and fertility; sexual function; perimenopausal and menopausal symptoms; and chronic pelvic pain syndromes. TARGET POPULATION The target population includes all women currently using or contemplating using opioids. OUTCOMES Open, evidence-informed dialogue about opioid use will lead to improvements in patient care and overall health. BENEFITS, HARMS, AND COSTS Exploring opioid use through a trauma-informed approach offers the health care provider and patient with an opportunity to build a strong, collaborative, and therapeutic alliance. This alliance empowers women to make informed choices about their own care. It also allows for the diagnosis and possible treatment of opioid use disorders. Use should not be stigmatized, as stigma leads to poor "partnered care" (i.e., the partnership between the patient and care provider). Therefore, health care providers and patients must understand the potential role of opioids in women's health (both positive and negative) to ensure informed decision-making. EVIDENCE A literature search was designed and carried out in PubMed and the Cochrane Library databases from August 2018 until March 2023 using following MeSH terms and keywords (and variants): opioids, illicit drugs, fertility, pregnancy, breastfeeding, and aging. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE All health care providers who care for women. TWEETABLE ABSTRACT Opioid use can affect female reproductive function; health care providers and patients must understand the potential role of opioids in women's health to ensure informed decision-making. SUMMARY STATEMENTS RECOMMENDATIONS.
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Turner S, Allen VM, Graves L, Tanguay R, Green CR, Cook JL. Directive clinique n o 443a : Opioïdes aux différentes étapes de la vie des femmes : Fertilité, contraception, douleur chronique et ménopause. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102145. [PMID: 37977725 DOI: 10.1016/j.jogc.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
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Turner S, Allen VM, Carson G, Graves L, Tanguay R, Green CR, Cook JL. Guideline No. 443b: Opioid Use Throughout Women's Lifespan: Opioid Use in Pregnancy and Breastfeeding. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102144. [PMID: 37977721 DOI: 10.1016/j.jogc.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
OBJECTIVE To provide health care providers the best evidence on opioid use and women's health. Areas of focus include pregnancy and postpartum care. TARGET POPULATION The target population includes all women currently using or contemplating using opioids. OUTCOMES Open, evidence-informed dialogue about opioid use will improve patient care. BENEFITS, HARMS, AND COSTS Exploring opioid use through a trauma-informed approach provides the health care provider and patient with an opportunity to build a strong, collaborative, and therapeutic alliance. This alliance empowers women to make informed choices about their own care. It also allows for the diagnosis and possible treatment of opioid use disorders. Opioid use should not be stigmatized, as stigma leads to poor "partnered care" (i.e., the partnership between the patient and care provider). Health care providers need to understand the effect opioids can have on pregnant women and support them to make knowledgeable decisions about their health. EVIDENCE A literature search was designed and carried out in PubMed and the Cochrane Library databases from August 2018 until March 2023 using following MeSH terms and keywords (and variants): opioids, opioid agonist therapy, illicit drugs, fertility, pregnancy, fetal development, neonatal abstinence syndrome, and breastfeeding. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE All health care providers who care for pregnant and/or post-partum women and their newborns. TWEETABLE ABSTRACT Opioid use during pregnancy often co-occurs with mental health issues and is associated with adverse maternal, fetal, and neonatal outcomes; treatment of opioid use disorder with agonist therapy for pregnant women can be safe during pregnancy where the risks outnumber the benefits. SUMMARY STATEMENTS RECOMMENDATIONS.
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Turner S, Allen VM, Carson G, Graves L, Tanguay R, Green CR, Cook JL. Directive clinique n o 443b : Opioïdes aux différentes étapes de la vie des femmes : Grossesse et allaitement. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102146. [PMID: 37977719 DOI: 10.1016/j.jogc.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
OBJECTIF Présenter aux professionnels de la santé les données probantes concernant l'utilisation des opioïdes et la santé des femmes. Les domaines d'intérêt sont la grossesse et les soins post-partum. POPULATION CIBLE Toutes les femmes qui utilisent des opioïdes. RéSULTATS: Un dialogue ouvert et éclairé sur l'utilisation des opioïdes améliorera les soins aux patientes. BéNéFICES, RISQUES ET COûTS: L'exploration de l'utilisation d'opioïdes par une approche tenant compte des traumatismes antérieurs donne au professionnel de la santé et à la patiente l'occasion de bâtir une alliance solide, collaborative et thérapeutique. Cette alliance permet aux femmes de faire des choix éclairés. Elle favorise le diagnostic et le traitement possible du trouble lié à l'utilisation d'opioïdes. L'utilisation ne doit pas être stigmatisée, puisque la stigmatisation affaiblit le partenariat (le partenariat entre patiente et professionnel de la santé). Les professionnels de la santé ceus-ci doivent comprendre l'effet potentiel des opioïdes sur la santé les femmes enceintes et les aider à prendre des décisions éclairées sur leur santé. DONNéES PROBANTES: Une recherche a été conçue puis effectuée dans les bases de données PubMed et Cochrane Library pour la période d'août 2018 à mars 2023 des termes MeSH et mots clés suivants (et variantes) : opioids, opioid agonist therapy, illicit drugs, fertility, pregnancy, fetal development, neonatal abstinence syndrome et breastfeeding. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Tous les professionnels de la santé qui prodiguent des soins aux femmes et aux nouveaux-nés. RéSUMé POUR TWITTER: La consommation d'opioïdes pendant la grossesse coïncide souvent avec des problèmes de santé mentale et est associée à des conséquences néfastes pour la mère, le fœtus et le nouveau-né ; le traitement des troubles liés à la consommation d'opioïdes par agonistes peut être sûr pendant la grossesse lorsque les risques sont plus nombreux que les avantages. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.
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Bista I, Wood JMD, Desvignes T, McCarthy SA, Matschiner M, Ning Z, Tracey A, Torrance J, Sims Y, Chow W, Smith M, Oliver K, Haggerty L, Salzburger W, Postlethwait JH, Howe K, Clark MS, William Detrich H, Christina Cheng CH, Miska EA, Durbin R. Genomics of cold adaptations in the Antarctic notothenioid fish radiation. Nat Commun 2023; 14:3412. [PMID: 37296119 PMCID: PMC10256766 DOI: 10.1038/s41467-023-38567-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/05/2023] [Indexed: 06/12/2023] Open
Abstract
Numerous novel adaptations characterise the radiation of notothenioids, the dominant fish group in the freezing seas of the Southern Ocean. To improve understanding of the evolution of this iconic fish group, here we generate and analyse new genome assemblies for 24 species covering all major subgroups of the radiation, including five long-read assemblies. We present a new estimate for the onset of the radiation at 10.7 million years ago, based on a time-calibrated phylogeny derived from genome-wide sequence data. We identify a two-fold variation in genome size, driven by expansion of multiple transposable element families, and use the long-read data to reconstruct two evolutionarily important, highly repetitive gene family loci. First, we present the most complete reconstruction to date of the antifreeze glycoprotein gene family, whose emergence enabled survival in sub-zero temperatures, showing the expansion of the antifreeze gene locus from the ancestral to the derived state. Second, we trace the loss of haemoglobin genes in icefishes, the only vertebrates lacking functional haemoglobins, through complete reconstruction of the two haemoglobin gene clusters across notothenioid families. Both the haemoglobin and antifreeze genomic loci are characterised by multiple transposon expansions that may have driven the evolutionary history of these genes.
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Affiliation(s)
- Iliana Bista
- Wellcome Sanger Institute, Tree of Life, Wellcome Genome Campus, Hinxton, CB10 1SA, UK.
- Department of Genetics, University of Cambridge, Downing Street, Cambridge, CB2 3EH, UK.
- Wellcome/CRUK Gurdon Institute, University of Cambridge, Tennis Court Rd, Cambridge, CB2 1QN, UK.
- Naturalis Biodiversity Center, Leiden, 2333 CR, the Netherlands.
| | - Jonathan M D Wood
- Wellcome Sanger Institute, Tree of Life, Wellcome Genome Campus, Hinxton, CB10 1SA, UK
| | - Thomas Desvignes
- University of Oregon, Institute of Neuroscience, 1254 University of Oregon, 13th Avenue, Eugene, OR, 97403, USA
| | - Shane A McCarthy
- Wellcome Sanger Institute, Tree of Life, Wellcome Genome Campus, Hinxton, CB10 1SA, UK
- Department of Genetics, University of Cambridge, Downing Street, Cambridge, CB2 3EH, UK
| | - Michael Matschiner
- University of Oslo, Natural History Museum, University of Oslo, Sars' gate 1, 0562, Oslo, Norway
- University of Zurich, Department of Palaeontology and Museum, University of Zurich, Karl-Schmid-Strasse 4, 8006, Zurich, Switzerland
| | - Zemin Ning
- Wellcome Sanger Institute, Tree of Life, Wellcome Genome Campus, Hinxton, CB10 1SA, UK
| | - Alan Tracey
- Wellcome Sanger Institute, Tree of Life, Wellcome Genome Campus, Hinxton, CB10 1SA, UK
| | - James Torrance
- Wellcome Sanger Institute, Tree of Life, Wellcome Genome Campus, Hinxton, CB10 1SA, UK
| | - Ying Sims
- Wellcome Sanger Institute, Tree of Life, Wellcome Genome Campus, Hinxton, CB10 1SA, UK
| | - William Chow
- Wellcome Sanger Institute, Tree of Life, Wellcome Genome Campus, Hinxton, CB10 1SA, UK
| | - Michelle Smith
- Wellcome Sanger Institute, Tree of Life, Wellcome Genome Campus, Hinxton, CB10 1SA, UK
| | - Karen Oliver
- Wellcome Sanger Institute, Tree of Life, Wellcome Genome Campus, Hinxton, CB10 1SA, UK
| | - Leanne Haggerty
- European Molecular Biology Laboratory, European Bioinformatics Institute, Wellcome Genome Campus, Hinxton, CB10 1SA, UK
| | - Walter Salzburger
- University of Basel, Zoological Institute, Department of Environmental Sciences, Vesalgasse 1, 4051, Basel, Switzerland
| | - John H Postlethwait
- University of Oregon, Institute of Neuroscience, 1254 University of Oregon, 13th Avenue, Eugene, OR, 97403, USA
| | - Kerstin Howe
- Wellcome Sanger Institute, Tree of Life, Wellcome Genome Campus, Hinxton, CB10 1SA, UK
| | - Melody S Clark
- British Antarctic Survey, High Cross, Madingley Road, Cambridge, CB3 0ET, UK
| | - H William Detrich
- Northeastern University, Department of Marine and Environmental Sciences, Marine Science Centre, 430 Nahant Rd., Nahant, MA, 01908, USA
| | - C-H Christina Cheng
- Department of Evolution, Ecology, and Behaviour, University of Illinois, Urbana-Champaign, IL, 61801, USA
| | - Eric A Miska
- Wellcome Sanger Institute, Tree of Life, Wellcome Genome Campus, Hinxton, CB10 1SA, UK
- Wellcome/CRUK Gurdon Institute, University of Cambridge, Tennis Court Rd, Cambridge, CB2 1QN, UK
| | - Richard Durbin
- Wellcome Sanger Institute, Tree of Life, Wellcome Genome Campus, Hinxton, CB10 1SA, UK.
- Department of Genetics, University of Cambridge, Downing Street, Cambridge, CB2 3EH, UK.
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Nielsen S, Tse WC, Larance B. Opioid agonist treatment for people who are dependent on pharmaceutical opioids. Cochrane Database Syst Rev 2022; 9:CD011117. [PMID: 36063082 PMCID: PMC9443668 DOI: 10.1002/14651858.cd011117.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND There are ongoing concerns regarding pharmaceutical opioid-related harms, including overdose and dependence, with an associated increase in treatment demand. People dependent on pharmaceutical opioids appear to differ in important ways from people who use heroin, yet most opioid agonist treatment research has been conducted in people who use heroin. OBJECTIVES: To assess the effects of maintenance opioid agonist pharmacotherapy for the treatment of pharmaceutical opioid dependence. SEARCH METHODS We updated our searches of the following databases to January 2022: the Cochrane Drugs and Alcohol Group Specialised Register, CENTRAL, MEDLINE, four other databases, and two trial registers. We checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). SELECTION CRITERIA We included RCTs with adults and adolescents examining maintenance opioid agonist treatments that made the following two comparisons. 1. Full opioid agonists (methadone, morphine, oxycodone, levo-alpha-acetylmethadol (LAAM), or codeine) versus different full opioid agonists or partial opioid agonists (buprenorphine) for maintenance treatment. 2. Full or partial opioid agonist maintenance versus non-opioid agonist treatments (detoxification, opioid antagonist, or psychological treatment without opioid agonist treatment). DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. MAIN RESULTS We identified eight RCTs that met inclusion criteria (709 participants). We found four studies that compared methadone and buprenorphine maintenance treatment, and four studies that compared buprenorphine maintenance to either buprenorphine taper (in addition to psychological treatment) or a non-opioid maintenance treatment comparison. We found low-certainty evidence from three studies of a difference between methadone and buprenorphine in favour of methadone on self-reported opioid use at end of treatment (risk ratio (RR) 0.49, 95% confidence interval (CI) 0.28 to 0.86; 165 participants), and low-certainty evidence from four studies finding a difference in favour of methadone for retention in treatment (RR 1.21, 95% CI 1.02 to 1.43; 379 participants). We found low-certainty evidence from three studies showing no difference between methadone and buprenorphine on substance use measured with urine drug screens at end of treatment (RR 0.81, 95% CI 0.57 to 1.17; 206 participants), and moderate-certainty evidence from one study of no difference in days of self-reported opioid use (mean difference 1.41 days, 95% CI 3.37 lower to 0.55 days higher; 129 participants). There was low-certainty evidence from three studies of no difference between methadone and buprenorphine on adverse events (RR 1.13, 95% CI 0.66 to 1.93; 206 participants). We found low-certainty evidence from four studies favouring maintenance buprenorphine treatment over non-opioid treatments in terms of fewer opioid positive urine drug tests at end of treatment (RR 0.66, 95% CI 0.52 to 0.84; 270 participants), and very low-certainty evidence from four studies finding no difference on self-reported opioid use in the past 30 days at end of treatment (RR 0.63, 95% CI 0.39 to 1.01; 276 participants). There was low-certainty evidence from three studies of no difference in the number of days of unsanctioned opioid use (standardised mean difference (SMD) -0.19, 95% CI -0.47 to 0.09; 205 participants). There was moderate-certainty evidence from four studies favouring buprenorphine maintenance over non-opioid treatments on retention in treatment (RR 3.02, 95% CI 1.73 to 5.27; 333 participants). There was moderate-certainty evidence from three studies of no difference in adverse effects between buprenorphine maintenance and non-opioid treatments (RR 0.50, 95% CI 0.07 to 3.48; 252 participants). The main weaknesses in the quality of the data was the use of open-label study designs, and difference in follow-up rates between treatment arms. AUTHORS' CONCLUSIONS There is very low- to moderate-certainty evidence supporting the use of maintenance agonist pharmacotherapy for pharmaceutical opioid dependence. Methadone or buprenorphine did not differ on some outcomes, although on the outcomes of retention and self-reported substance use some results favoured methadone. Maintenance treatment with buprenorphine appears more effective than non-opioid treatments. Due to the overall very low- to moderate-certainty evidence and small sample sizes, there is the possibility that the further research may change these findings.
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Affiliation(s)
- Suzanne Nielsen
- Monash Addiction Research Centre, Monash University, Frankston, Australia
| | - Wai Chung Tse
- Monash Addiction Research Centre, Monash University, Frankston, Australia
- School of Medicine, Monash University, Melbourne, Australia
| | - Briony Larance
- School of Psychology, Faculty of the Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, Australia
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Lim J, Farhat I, Douros A, Panagiotoglou D. Relative effectiveness of medications for opioid-related disorders: A systematic review and network meta-analysis of randomized controlled trials. PLoS One 2022; 17:e0266142. [PMID: 35358261 PMCID: PMC8970369 DOI: 10.1371/journal.pone.0266142] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/15/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Several pharmacotherapeutic interventions are available for maintenance treatment for opioid-related disorders. However, previous meta-analyses have been limited to pairwise comparisons of these interventions, and their efficacy relative to all others remains unclear. Our objective was to unify findings from different healthcare practices and generate evidence to strengthen clinical treatment protocols for the most widely prescribed medications for opioid-use disorders. METHODS We searched Medline, EMBASE, PsycINFO, CENTRAL, and ClinicalTrials.gov for all relevant randomized controlled trials (RCT) from database inception to February 12, 2022. Primary outcome was treatment retention, and secondary outcome was opioid use measured by urinalysis. We calculated risk ratios (RR) and 95% credible interval (CrI) using Bayesian network meta-analysis (NMA) for available evidence. We assessed the credibility of the NMA using the Confidence in Network Meta-Analysis tool. RESULTS Seventy-nine RCTs met the inclusion criteria. Due to heterogeneity in measuring opioid use and reporting format between studies, we conducted NMA only for treatment retention. Methadone was the highest ranked intervention (Surface Under the Cumulative Ranking [SUCRA] = 0.901) in the network with control being the lowest (SUCRA = 0.000). Methadone was superior to buprenorphine for treatment retention (RR = 1.22; 95% CrI = 1.06-1.40) and buprenorphine superior to naltrexone (RR = 1.39; 95% CrI = 1.10-1.80). However, due to a limited number of high-quality trials, confidence in the network estimates of other treatment pairs involving naltrexone and slow-release oral morphine (SROM) remains low. CONCLUSION All treatments had higher retention than the non-pharmacotherapeutic control group. However, additional high-quality RCTs are needed to estimate more accurately the extent of efficacy of naltrexone and SROM relative to other medications. For pharmacotherapies with established efficacy profiles, assessment of their long-term comparative effectiveness may be warranted. TRIAL REGISTRATION This systematic review has been registered with PROSPERO (https://www.crd.york.ac.uk/prospero) (identifier CRD42021256212).
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Affiliation(s)
- Jihoon Lim
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
| | - Imen Farhat
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
| | - Antonios Douros
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
- Department of Medicine, McGill University, Montreal, QC, Canada
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada
- Institute of Clinical Pharmacology and Toxicology, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Dimitra Panagiotoglou
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
- * E-mail:
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Hammond CJ, Kady A, Park G, Vidal C, Wenzel K, Fishman M. Therapy Dose Mediates the Relationship Between Buprenorphine/Naloxone and Opioid Treatment Outcomes in Youth Receiving Medication for Opioid Use Disorder Treatment. J Addict Med 2022; 16:e97-e104. [PMID: 33973923 DOI: 10.1097/adm.0000000000000861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Evidence-based interventions for treating opioid use disorder (OUD) in youth are limited and little is known about specific and general mechanisms of OUD treatments and how they promote abstinence. METHODS The present study used data from the NIDA-CTN-0010 trial to evaluate the mediating effects of psychosocial treatment-related variables (therapy dose and therapeutic alliance) on end-of-treatment opioid abstinence in a sample of youth with OUD (n = 152, 40% female, mean age = 19.7 years) randomized to receive either 12-weeks of treatment with Bup/Nal ("Bup-Nal") or up to 2 weeks of Bup/Nal detoxification ("Detox") with both treatment arms receiving weekly individual and group drug counseling ± family therapy. RESULTS Participants in the Bup-Nal group attended more therapy sessions (16 vs 6 sessions), had increased therapeutic alliance at week-4, and had less opioid use by week-12 compared to those in the Detox group. In both treatment arms, youth who attended more therapy sessions were less likely to have a week-12 opioid positive urine. In a multiple mediator model, therapy dose mediated the association between treatment arm and opioid abstinence. CONCLUSIONS These findings provide preliminary support for a "dose-response" effect of addiction-focused therapy on abstinence in youth OUD. Further, the results identified a mediating effect of therapy dose on the relationship between treatment assignment and opioid treatment outcomes, suggesting that extended Bup-Nal treatment may enhance abstinence, in part, through a mechanism of therapy facilitation, by increasing therapy dose during treatment.
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Affiliation(s)
- Christopher J Hammond
- Division of Child & Adolescent Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD (CJH, AK, GP, CV, MF), Behavioral Pharmacology Research Unit, Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD (CJH), Maryland Treatment Centers, Baltimore, MD (KW, MF)
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Davidson PJ, Bowles JM, Faul M, Gaines TL. Spatial proximity and access to buprenorphine or methadone treatment for opioid use disorder in a sample of people misusing opioids in Southern California. J Subst Abuse Treat 2022; 132:108634. [PMID: 34625318 PMCID: PMC10465062 DOI: 10.1016/j.jsat.2021.108634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 07/15/2021] [Accepted: 09/14/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND In response to the opioid crisis, over the last 10 years substantial strides have been made to increase the availability of evidence-based treatments for opioid use disorder, in particular buprenorphine maintenance, in the United States. Despite these worthwhile efforts, uptake rates of evidence-based treatment remain relatively low. As part of a broader study of opioid misuse, we examined proximity to evidence-based treatment as a potential barrier to treatment access. METHODS In 2017-2018, we surveyed 218 individuals misusing prescription opioids or using street opioids in three Southern Californian counties. The study calculated driving distance from place of residence to the closest treatment provider offering buprenorphine or methadone treatment for opioid use disorders. RESULTS Median distance to providers was 3.8 km (2.4 miles). Seventy one (33%) participants had received some form of treatment in the last 3 months; however, only 26 (40%) of these had received buprenorphine or methadone maintenance treatment. Participants receiving treatment at the time of their interview were traveling an average 16.8 km (10.4 miles) to reach treatment, indicating that as a group this population was both willing and able to seek and engage with treatment. CONCLUSIONS In the suburban and exurban communities in which our study was based, our findings suggest that simple physical proximity to providers of evidence-based treatment for opioid use disorder is no longer a critical barrier. Other barriers to uptake of buprenorphine or methadone maintenance treatment clearly remain and need to be addressed. DISCLAIMER Findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
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Affiliation(s)
- P J Davidson
- University of California, San Diego, Department of Medicine, 9500 Gilman Dr, La Jolla, CA 92093-0507, USA.
| | - J M Bowles
- University of California, San Diego, Department of Medicine, 9500 Gilman Dr, La Jolla, CA 92093-0507, USA; Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria St., Toronto, Ontario M5B 3M6, Canada
| | - M Faul
- Health Systems and Trauma Systems Branch, Mailstop F-62, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329, USA
| | - T L Gaines
- University of California, San Diego, Department of Medicine, 9500 Gilman Dr, La Jolla, CA 92093-0507, USA
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Soled D, Uppal N, Weiner SG. Breaking the cycle: A public-private partnership to combat the American opioid epidemic. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2021; 9:100592. [PMID: 34739979 DOI: 10.1016/j.hjdsi.2021.100592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 10/18/2021] [Accepted: 10/25/2021] [Indexed: 11/16/2022]
Abstract
There has been an increased focus on the opioid epidemic in the United States, yet policy-based interventions such as prescription limits, restrictions on doctor shopping, and notification programs for high-volume prescribers have had no significant impact. In this paper, the authors explore a novel public health policy: a joint public-private partnership between the federal government and hospitals to establish long-term treatment centers for patients admitted to the emergency department after an overdose. These centers would provide medication for opioid use disorder, give individuals the necessary support for recovery, and reduce healthcare expenditures. Similar longitudinal strategies may be used in other areas of public health.
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Affiliation(s)
- Derek Soled
- Harvard Medical School, Boston, MA, USA; Harvard Business School, Boston, MA, USA.
| | - Nishant Uppal
- Harvard Medical School, Boston, MA, USA; Harvard Business School, Boston, MA, USA.
| | - Scott G Weiner
- Harvard Medical School, Boston, MA, USA; Brigham and Women's Hospital, Boston, MA, USA
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Nalven T, Spillane NS, Schick MR, Weyandt LL. Diversity inclusion in United States opioid pharmacological treatment trials: A systematic review. Exp Clin Psychopharmacol 2021; 29:524-538. [PMID: 34242040 PMCID: PMC8511246 DOI: 10.1037/pha0000510] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pharmacological treatments for opioid use disorders (OUDs) may have mixed efficacy across diverse groups, i.e., sex/gender, race/ethnicity, and socioeconomic status (SES). The present systematic review aims to examine how diverse groups have been included in U.S. randomized clinical trials examining pharmacological treatments (i.e., methadone, buprenorphine, or naltrexone) for OUDs. PubMed was systematically searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The initial search yielded 567 articles. After exclusion of ineligible articles, 50 remained for the present review. Of the included articles, 14.0% (n = 7) reported both full (i.e., accounting for all participants) sex/gender and race/ethnicity information; only two of those articles also included information about any SES indicators. Moreover, only 22.0% (n = 11) reported full sex/gender information, and 42.0% (n = 21) reported full racial/ethnic information. Furthermore, only 10.0% (n = 5) reported that their lack of subgroup analyses or diverse samples was a limitation to their studies. Particularly underrepresented were American Indian/Alaska Native (AI/AN), Asian, Native Hawaiian/Other Pacific Islander (NH/OPI), and multiracial individuals. These results also varied by medication type; Black individuals were underrepresented in buprenorphine randomized controlled trials (RCTs) but were well represented in RCTs for methadone and/or naltrexone. In conclusion, it is critical that all people receive efficacious pharmacological care for OUDs given the ongoing opioid epidemic. Findings from the present review, however, support that participants from diverse or marginalized backgrounds are underrepresented in treatment trials, despite being at increased risk for disparities related to OUDs. Suggestions for future research are advanced. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Tessa Nalven
- Department of Psychology, University of Rhode Island
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12
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Santo T, Clark B, Hickman M, Grebely J, Campbell G, Sordo L, Chen A, Tran LT, Bharat C, Padmanathan P, Cousins G, Dupouy J, Kelty E, Muga R, Nosyk B, Min J, Pavarin R, Farrell M, Degenhardt L. Association of Opioid Agonist Treatment With All-Cause Mortality and Specific Causes of Death Among People With Opioid Dependence: A Systematic Review and Meta-analysis. JAMA Psychiatry 2021; 78:979-993. [PMID: 34076676 PMCID: PMC8173472 DOI: 10.1001/jamapsychiatry.2021.0976] [Citation(s) in RCA: 234] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/01/2021] [Indexed: 12/11/2022]
Abstract
Importance Mortality among people with opioid dependence is higher than that of the general population. Opioid agonist treatment (OAT) is an effective treatment for opioid dependence; however, there has not yet been a systematic review on the relationship between OAT and specific causes of mortality. Objective To estimate the association of time receiving OAT with mortality. Data Sources The Embase, MEDLINE, and PsycINFO databases were searched through February 18, 2020, including clinical trial registries and previous Cochrane reviews. Study Selection All observational studies that collected data on all-cause or cause-specific mortality among people with opioid dependence while receiving and not receiving OAT were included. Randomized clinical trials (RCTs) were also included. Data Extraction and Synthesis This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Data on study, participant, and treatment characteristics were extracted; person-years, all-cause mortality, and cause-specific mortality were calculated. Crude mortality rates and rate ratios (RRs) were pooled using random-effects meta-analyses. Main Outcomes and Measures Overall all-cause and cause-specific mortality both by setting and by participant characteristics. Methadone and buprenorphine OAT were evaluated specifically. Results Fifteen RCTs including 3852 participants and 36 primary cohort studies including 749 634 participants were analyzed. Among the cohort studies, the rate of all-cause mortality during OAT was more than half of the rate seen during time out of OAT (RR, 0.47; 95% CI, 0.42-0.53). This association was consistent regardless of patient sex, age, geographic location, HIV status, and hepatitis C virus status and whether drugs were taken through injection. Associations were not different for methadone (RR, 0.47; 95% CI, 0.41-0.54) vs buprenorphine (RR, 0.34; 95% CI, 0.26-0.45). There was lower risk of suicide (RR, 0.48; 95% CI, 0.37-0.61), cancer (RR, 0.72; 95% CI, 0.52-0.98), drug-related (RR, 0.41; 95% CI, 0.33-0.52), alcohol-related (RR, 0.59; 95% CI, 0.49-0.72), and cardiovascular-related (RR, 0.69; 95% CI, 0.60-0.79) mortality during OAT. In the first 4 weeks of methadone treatment, rates of all-cause mortality and drug-related poisoning were almost double the rates during the remainder of OAT (RR, 2.01; 95% CI, 1.55-5.09) but not for buprenorphine (RR, 0.58; 95% CI, 0.18-1.85). All-cause mortality was 6 times higher in the 4 weeks after OAT cessation (RR, 6.01; 95% CI, 4.32-8.36), remaining double the rate for the remainder of time not receiving OAT (RR, 1.81; 95% CI, 1.50-2.18). Opioid agonist treatment was associated with a lower risk of mortality during incarceration (RR, 0.06; 95% CI, 0.01-0.46) and after release from incarceration (RR, 0.09; 95% CI, 0.02-0.56). Conclusions and Relevance This systematic review and meta-analysis found that OAT was associated with lower rates of mortality. However, access to OAT remains limited, and coverage of OAT remains low. Work to improve access globally may have important population-level benefits.
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Affiliation(s)
- Thomas Santo
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Sydney, Australia
| | - Brodie Clark
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Sydney, Australia
| | - Matt Hickman
- Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Jason Grebely
- Kirby Institute, University of New South Wales, Sydney, Sydney, Australia
| | - Gabrielle Campbell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Sydney, Australia
- University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
| | - Luis Sordo
- Consortium for Biomedical Research in Epidemiology and Public Health, Madrid, Spain
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Aileen Chen
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Sydney, Australia
- Clinical Research Unit for Anxiety and Depression, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Lucy Thi Tran
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Sydney, Australia
| | - Chrianna Bharat
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Sydney, Australia
| | | | - Grainne Cousins
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Julie Dupouy
- University Department of General Medicine, University of Toulouse, Faculty of Medicine, Toulouse, France
- Inserm UMR1027, University of Toulouse III, Faculty of Medicine, Toulouse, France
| | - Erin Kelty
- The School of Population & Global Health, The University of Western Australia, Perth, Australia
| | - Roberto Muga
- Department of Internal Medicine, Germans Trias i Pujol-IGTP University Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Bohdan Nosyk
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Jeong Min
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Raimondo Pavarin
- Epidemiological Monitoring Center on Addiction, Azienda Unità Sanitaria Locale Bologna, Mental Health Dipartimento Salute Mentale – Dipendenze Patologiche, Bologna, Italy
- Italian Society on Addiction, Milan, Italy
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Sydney, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Sydney, Australia
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McCarty D, Chan B, Bougatsos C, Grusing S, Chou R. Interim methadone - Effective but underutilized: A scoping review. Drug Alcohol Depend 2021; 225:108766. [PMID: 34051546 DOI: 10.1016/j.drugalcdep.2021.108766] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 03/30/2021] [Accepted: 04/01/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Opioid treatment programs (OTPs) may provide interim methadone services - up to 120 days of methadone dosing without counseling. Regulatory requirements limit use of interim methadone services. We summarized the evidence on interim methadone and other strategies to minimize wait lists in OTPs. METHODS A scoping review selected studies of interim methadone and strategies that facilitated access to methadone. Randomized trials and controlled observational studies were prioritized; if evidence was lacking, lesser quality evidence was included. RESULTS Six studies examined interim methadone and three studies examined alternatives: low threshold services, an open access policy, and a medication first policy. The studies included four randomized clinical trials of interim methadone (with three follow-up reports and five secondary analyses), one prospective cohort of interim methadone, one retrospective cohort of interim methadone, one randomized trial of low threshold services and two pre-post assessments of changes in program or state policies. The clinical trials and observational cohorts reported reductions in heroin use during interim methadone and participants were more likely to enter OTPs than those on wait lists. Retention rates in interim methadone were similar to patients in active treatment. Studies testing strategies to facilitate access to methadone were effective without interim methadone's restrictions. CONCLUSION Interim methadone appears to be effective and safe compared to wait list controls and provided similar outcomes to standard services. Interim methadone could increase access to OTPs. More research is needed on the alternative approaches to facilitate access to medication with comparisons to wait list controls and assessment of patient outcomes.
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Affiliation(s)
- Dennis McCarty
- Pacific Northwest Evidence-Based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, BICC, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, United States; OHSU-PSU School of Public Health, Oregon Health & Science University, CB669, United States.
| | - Brian Chan
- Department of Medicine, OHSU Medical School, Oregon Health & Science University, United States
| | - Christina Bougatsos
- Pacific Northwest Evidence-Based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, BICC, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, United States
| | - Sara Grusing
- Pacific Northwest Evidence-Based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, BICC, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, United States
| | - Roger Chou
- Pacific Northwest Evidence-Based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, BICC, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, United States
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14
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Fairley M, Humphreys K, Joyce VR, Bounthavong M, Trafton J, Combs A, Oliva EM, Goldhaber-Fiebert JD, Asch SM, Brandeau ML, Owens DK. Cost-effectiveness of Treatments for Opioid Use Disorder. JAMA Psychiatry 2021; 78:767-777. [PMID: 33787832 PMCID: PMC8014209 DOI: 10.1001/jamapsychiatry.2021.0247] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
IMPORTANCE Opioid use disorder (OUD) is a significant cause of morbidity and mortality in the US, yet many individuals with OUD do not receive treatment. OBJECTIVE To assess the cost-effectiveness of OUD treatments and association of these treatments with outcomes in the US. DESIGN AND SETTING This model-based cost-effectiveness analysis included a US population with OUD. INTERVENTIONS Medication-assisted treatment (MAT) with buprenorphine, methadone, or injectable extended-release naltrexone; psychotherapy (beyond standard counseling); overdose education and naloxone distribution (OEND); and contingency management (CM). MAIN OUTCOMES AND MEASURES Fatal and nonfatal overdoses and deaths throughout 5 years, discounted lifetime quality-adjusted life-years (QALYs), and costs. RESULTS In the base case, in the absence of treatment, 42 717 overdoses (4132 fatal, 38 585 nonfatal) and 12 660 deaths were estimated to occur in a cohort of 100 000 patients over 5 years, and 11.58 discounted lifetime QALYs were estimated to be experienced per person. An estimated reduction in overdoses was associated with MAT with methadone (10.7%), MAT with buprenorphine or naltrexone (22.0%), and when combined with CM and psychotherapy (range, 21.0%-31.4%). Estimated deceased deaths were associated with MAT with methadone (6%), MAT with buprenorphine or naltrexone (13.9%), and when combined with CM, OEND, and psychotherapy (16.9%). MAT yielded discounted gains of 1.02 to 1.07 QALYs per person. Including only health care sector costs, methadone cost $16 000/QALY gained compared with no treatment, followed by methadone with OEND ($22 000/QALY gained), then by buprenorphine with OEND and CM ($42 000/QALY gained), and then by buprenorphine with OEND, CM, and psychotherapy ($250 000/QALY gained). MAT with naltrexone was dominated by other treatment alternatives. When criminal justice costs were included, all forms of MAT (with buprenorphine, methadone, and naltrexone) were associated with cost savings compared with no treatment, yielding savings of $25 000 to $105 000 in lifetime costs per person. The largest cost savings were associated with methadone plus CM. Results were qualitatively unchanged over a wide range of sensitivity analyses. An analysis using demographic and cost data for Veterans Health Administration patients yielded similar findings. CONCLUSIONS AND RELEVANCE In this cost-effectiveness analysis, expanded access to MAT, combined with OEND and CM, was associated with cost-saving reductions in morbidity and mortality from OUD. Lack of widespread MAT availability limits access to a cost-saving medical intervention that reduces morbidity and mortality from OUD. Opioid overdoses in the US likely reached a record high in 2020 because of COVID-19 increasing substance use, exacerbating stress and social isolation, and interfering with opioid treatment. It is essential to understand the cost-effectiveness of alternative forms of MAT to treat OUD.
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Affiliation(s)
- Michael Fairley
- Department of Management Science and Engineering, Stanford University, Stanford, California
| | - Keith Humphreys
- Center for Innovation to Implementation, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, California,Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
| | - Vilija R. Joyce
- Veterans Affairs Health Services Research and Development Health Economics Resource Center, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, California
| | - Mark Bounthavong
- Veterans Affairs Health Services Research and Development Health Economics Resource Center, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, California
| | - Jodie Trafton
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California,Veterans Affairs Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, VA Central Office, US Department of Veterans Affairs, Palo Alto, California
| | - Ann Combs
- Veterans Affairs Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, VA Central Office, US Department of Veterans Affairs, Palo Alto, California
| | - Elizabeth M. Oliva
- Center for Innovation to Implementation, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, California
| | - Jeremy D. Goldhaber-Fiebert
- Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, California
| | - Steven M. Asch
- Center for Innovation to Implementation, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, California,Department of Medicine, Stanford University, Stanford, California
| | - Margaret L. Brandeau
- Department of Management Science and Engineering, Stanford University, Stanford, California
| | - Douglas K. Owens
- Center for Innovation to Implementation, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, California,Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, California,Department of Medicine, Stanford University, Stanford, California
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15
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Marks LR, Munigala S, Warren DK, Liss DB, Liang SY, Schwarz ES, Durkin MJ. A Comparison of Medication for Opioid Use Disorder Treatment Strategies for Persons Who Inject Drugs With Invasive Bacterial and Fungal Infections. J Infect Dis 2021; 222:S513-S520. [PMID: 32877547 DOI: 10.1093/infdis/jiz516] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Patients with opioid use disorder (OUD) are frequently admitted for invasive infections. Medications for OUD (MOUD) may improve outcomes in hospitalized patients. METHODS In this retrospective cohort of 220 admissions to a tertiary care center for invasive infections due to OUD, we compared 4 MOUD treatment strategies: methadone, buprenorphine, methadone taper for detoxification, and no medication to determine whether there were differences in parenteral antibiotic completion and readmission rates. RESULTS The MOUDs were associated with increased completion of parenteral antimicrobial therapy (64.08% vs 46.15%; odds ratio [OR] = 2.08; 95% CI, 1.23-3.61). On multivariate analysis, use of MOUD maintenance with either buprenorphine (OR = 0.38; 95% CI, .17-.85) or methadone maintenance (OR = 0.43; 95% CI, .20-.94) and continuation of MOUD on discharge (OR = 0.35; 95% CI, .18-.67) was associated with lower 90-day readmissions. In contrast, use of methadone for detoxification followed by tapering of the medication without continuation on discharge was not associated with decreased readmissions (OR = 1.87; 95% CI, .62-5.10). CONCLUSIONS Long-term MOUDs, regardless of selection, are an integral component of care in patients hospitalized with OUD-related infections. Patients with OUD should have arrangements made for MOUDs to be continued after discharge, and MOUDs should not be discontinued before discharge.
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Affiliation(s)
- Laura R Marks
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Satish Munigala
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - David K Warren
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - David B Liss
- Division of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA.,Section of Medical Toxicology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Stephen Y Liang
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA.,Division of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Evan S Schwarz
- Division of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA.,Section of Medical Toxicology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Michael J Durkin
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
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16
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Haeny AM, Montgomery L, Burlew AK, Campbell ANC, Scodes J, Pavlicova M, Rotrosen J, Nunes E. Extended-release naltrexone versus buprenorphine-naloxone to treat opioid use disorder among black adults. Addict Behav 2020; 110:106514. [PMID: 32619868 PMCID: PMC7433932 DOI: 10.1016/j.addbeh.2020.106514] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 05/16/2020] [Accepted: 06/12/2020] [Indexed: 10/24/2022]
Abstract
Few studies examine the effectiveness of treatments for opioid use disorder (OUD) among Black individuals despite recent evidence suggesting opioid overdose death rates are, in some cases, highest and increasing at a faster rate among Black people compared to other racial/ethnic groups. This secondary analysis study investigated treatment preference, retention, and relapse rates amongst a subgroup of 73 Black participants with OUD (81% male, mean age 39.05, SD = 11.80) participating in a 24-week multisite randomized clinical trial ("X:BOT") comparing the effectiveness of extended-release naltrexone (XR-NTX) and sublingual buprenorphine-naloxone (BUP-NX) between 2014 and 2017. Chi-square analyses were used to investigate treatment preference assessed at baseline, and logistic regression analyses were used to investigate differences in the odds of retention and relapse assessed over the 24-week course of treatment between treatment groups. Our findings suggest no differences in preference for XR-NTX versus BUP-NX. However, similar to the parent trial, there was an induction hurdle such that only 59.5% of those randomized to XR-NTX successfully initiated medication compared to 91.6% of those randomized to BUP-NX (OR = 0.13, 95% CI = 0.04, 0.52). No significant differences were found in treatment retention (intention-to-treat: OR = 1.19, 95% CI = 0.43, 3.28; per-protocol [i.e., those who initiated medication]: OR = 0.60, 95% CI = 0.20, 1.82) or relapse rates between treatment groups (intention-to-treat: OR = 1.53, 95% CI = 0.57, 4.13; per-protocol: OR = 0.69, 95% CI = 0.23, 2.06). Although there is a significant initiation hurdle with XR-NTX, once inducted, both medications appear similar in effectiveness, but as in the main study, dropout rates were high. Future research is needed on how to improve adherence.
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Affiliation(s)
- Angela M Haeny
- Yale School of Medicine, Department of Psychiatry, 34 Park St., New Haven, CT 06511, United States.
| | - LaTrice Montgomery
- University of Cincinnati, Department of Psychiatry and Behavioral Neuroscience, 3131 Harvey Avenue., Cincinnati, OH 45229, United States
| | - A Kathleen Burlew
- University of Cincinnati, Department of Psychology, 2600 Clifton Ave., Cincinnati, OH 45221, United States
| | - Aimee N C Campbell
- Columbia University Irving Medical Center, Department of Psychiatry and New York State Psychiatric Institute, 1051 Riverside Dr., New York, NY 10032, United States
| | - Jennifer Scodes
- Columbia University Irving Medical Center, Department of Psychiatry and New York State Psychiatric Institute, 1051 Riverside Dr., New York, NY 10032, United States
| | - Martina Pavlicova
- Columbia University Irving Medical Center, Department of Psychiatry and New York State Psychiatric Institute, 1051 Riverside Dr., New York, NY 10032, United States
| | - John Rotrosen
- New York University Grossman School of Medicine, One Park Ave., New York, NY 10016, United States
| | - Edward Nunes
- Columbia University Irving Medical Center, Department of Psychiatry and New York State Psychiatric Institute, 1051 Riverside Dr., New York, NY 10032, United States
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17
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Patnode CD, Perdue LA, Rushkin M, Dana T, Blazina I, Bougatsos C, Grusing S, O'Connor EA, Fu R, Chou R. Screening for Unhealthy Drug Use: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2020; 323:2310-2328. [PMID: 32515820 DOI: 10.1001/jama.2019.21381] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
IMPORTANCE Illicit drug use is among the most common causes of preventable morbidity and mortality in the US. OBJECTIVE To systematically review the literature on screening and interventions for drug use to inform the US Preventive Services Task Force. DATA SOURCES MEDLINE, PubMed, PsycINFO, Embase, and Cochrane Central Register of Controlled Trials through September 18, 2018; literature surveillance through September 21, 2019. STUDY SELECTION Test accuracy studies to detect drug misuse and randomized clinical trials of screening and interventions to reduce drug use. DATA EXTRACTION AND SYNTHESIS Critical appraisal and data abstraction by 2 reviewers and random-effects meta-analyses. MAIN OUTCOMES AND MEASURES Sensitivity, specificity, drug use and other health, social, and legal outcomes. RESULTS Ninety-nine studies (N = 84 206) were included. Twenty-eight studies (n = 65 720) addressed drug screening accuracy. Among adults, sensitivity and specificity of screening tools for detecting unhealthy drug use ranged from 0.71 to 0.94 and 0.87 to 0.97, respectively. Interventions to reduce drug use were evaluated in 52 trials (n = 15 659) of psychosocial interventions, 7 trials (n = 1109) of opioid agonist therapy, and 13 trials (n = 1718) of naltrexone. Psychosocial interventions were associated with increased likelihood of drug use abstinence (15 trials, n = 3636; relative risk [RR], 1.60 [95% CI, 1.24 to 2.13]; absolute risk difference [ARD], 9% [95% CI, 5% to 15%]) and reduced number of drug use days (19 trials, n = 5085; mean difference, -0.49 day in the last 7 days [95% CI, -0.85 to -0.13]) vs no psychosocial intervention at 3- to 4-month follow-up. In treatment-seeking populations, opioid agonist therapy and naltrexone were associated with decreased risk of drug use relapse (4 trials, n = 567; RR, 0.75 [95% CI, 0.59 to 0.82]; ARD, -35% [95% CI, -67% to -3%] and 12 trials, n = 1599; RR, 0.73 [95% CI, 0.62 to 0.85]; ARD, -18% [95% CI, -26% to -10%], respectively) vs placebo or no medication. While evidence on harms was limited, it indicated no increased risk of serious adverse events. CONCLUSIONS AND RELEVANCE Several screening instruments with acceptable sensitivity and specificity are available to screen for drug use, although there is no direct evidence on the benefits or harms of screening. Pharmacotherapy and psychosocial interventions are effective at improving drug use outcomes, but evidence of effectiveness remains primarily derived from trials conducted in treatment-seeking populations.
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Affiliation(s)
- Carrie D Patnode
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Leslie A Perdue
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Megan Rushkin
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Tracy Dana
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Ian Blazina
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Christina Bougatsos
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Sara Grusing
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Elizabeth A O'Connor
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Rongwei Fu
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
- School of Public Health, Oregon Health & Science University-Portland State University, Portland
| | - Roger Chou
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
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18
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Harvey LM, Fan W, Cano MÁ, Vaughan EL, Arbona C, Essa S, Sanchez H, de Dios MA. Psychosocial intervention utilization and substance abuse treatment outcomes in a multisite sample of individuals who use opioids. J Subst Abuse Treat 2020; 112:68-75. [PMID: 32199548 DOI: 10.1016/j.jsat.2020.01.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 12/30/2019] [Accepted: 01/24/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND There are several relatively safe and effective FDA-approved medications for Opioid Use Disorder (OUD). Despite the existence of these medications, the rate of returning to opioid use after treatment is relatively high, underscoring the need for continued enhancement of treatments. Adjunctive psychosocial interventions paired with medication have been shown to improve OUD treatment outcomes. However, studies have yet to conclusively examine the distinct effects of the most widely utilized psychosocial treatment modalities. The current study will investigate the relationship between individual counseling, group therapy, and 12-Step participation and illicit opioid abstinence at the end of treatment, 1 and 3 months after treatment. METHOD A secondary analysis was conducted with data from a sample of 570 individuals diagnosed with OUD who were recruited from eight substance abuse treatment centers in the United States. Participants were enrolled in a two-group randomized, controlled trial testing buprenorphine-naloxone versus extended-release naltrexone for OUD. A two-level hierarchical linear growth model was used to examine the effects of individual counseling, group therapy, and 12-Step participation on illicit opioid abstinence (urinanalyses) 1- and 3-months post-treatment. RESULTS Hours of individual counseling and 12-Step participation significantly predicted abstinence at follow-up (p < .001, b = -0.59, 95% CI [0.42, 0.74]; p < .01, b = -0.05, 95% CI [0.92, 0.98]). There was a significant interaction between individual counseling and 12-Step participation (p < .01, b = -0.06, 95% CI [1.02, 1.10]). Additionally, participant age and employment status were significant predictors of illicit opioid abstinence (p < .01, b = -0.02, 95% CI [0.97, 0.99]; p < .01, b = -0.38, 95% CI [0.52, 0.90]). Hours of group therapy was not found to significantly predict illicit opioid abstinence. CONCLUSIONS Findings suggest that greater levels of individual therapy and 12-Step participation may be beneficial for individuals receiving medication treatment for OUD.
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Affiliation(s)
- Laura M Harvey
- Department of Psychological, Health, & Learning Sciences, University of Houston, 3657 Cullen Blvd, Houston, TX 77204, United States
| | - Weihua Fan
- Department of Psychological, Health, & Learning Sciences, University of Houston, 3657 Cullen Blvd, Houston, TX 77204, United States
| | - Miguel Ángel Cano
- Department of Epidemiology, Florida International University, 11200 SW 8th St AHC5, Miami, FL 33199, United States
| | - Ellen L Vaughan
- Department of Counseling and Educational Psychology, Indiana University, 201 N Rose Ave, Bloomington, IN 47405, United States
| | - Consuelo Arbona
- Department of Psychological, Health, & Learning Sciences, University of Houston, 3657 Cullen Blvd, Houston, TX 77204, United States
| | - Saman Essa
- Department of Psychological, Health, & Learning Sciences, University of Houston, 3657 Cullen Blvd, Houston, TX 77204, United States
| | - Helen Sanchez
- Department of Psychological, Health, & Learning Sciences, University of Houston, 3657 Cullen Blvd, Houston, TX 77204, United States
| | - Marcel A de Dios
- Department of Psychological, Health, & Learning Sciences, University of Houston, 3657 Cullen Blvd, Houston, TX 77204, United States; HEALTH Research Institute, University of Houston, 4849 Calhoun Rd, Houston, TX 77204, United States.
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Carroll KM, Weiss RD. The Role of Behavioral Interventions in Buprenorphine Maintenance Treatment: A Review. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2020; 17:183-192. [PMID: 32021588 DOI: 10.1176/appi.focus.17206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
(Reprinted with permission from Am J Psychiatry 2017;174:738-747).
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Affiliation(s)
- Kathleen M Carroll
- Department of Psychiatry, Yale University School of Medicine, West Haven, Conn.; the Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, Mass.; and the Department of Psychiatry, Harvard Medical School, Boston
| | - Roger D Weiss
- Department of Psychiatry, Yale University School of Medicine, West Haven, Conn.; the Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, Mass.; and the Department of Psychiatry, Harvard Medical School, Boston
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Schwartz R, Kelly S, Mitchell S, O’Grady K, Sharma A, Jaffe J. Methadone treatment of arrestees: A randomized clinical trial. Drug Alcohol Depend 2020; 206:107680. [PMID: 31753737 PMCID: PMC6980707 DOI: 10.1016/j.drugalcdep.2019.107680] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 10/04/2019] [Accepted: 10/09/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Opioid use disorder is common among detainees in US jails, yet methadone treatment is rarely initiated. METHODS This is a three-group randomized controlled trial in which 225 detainees in Baltimore treated for opioid withdrawal were assigned to: (1) interim methadone (IM) with patient navigation (IM + PN); (2) IM; or (3) enhanced treatment-as-usual (ETAU). Participants in both IM groups were able to enter standard methadone treatment upon release, while ETAU participants received an assessment/referral number. Follow-up assessments at 1, 3, 6, and 12 months post-release determined treatment enrollment, urine drug testing results, self-reported days of drug use, criminal activity, and overdose events. Generalized linear mixed modelling examined two planned contrasts: (1) IM groups combined vs. ETAU; and (2) IM + PN vs. IM. RESULTS On an intention-to-treat basis, compared to ETAU, significantly more participants in the combined IM groups were in treatment 30 days post-release, while the IM + PN vs. IM groups did not significantly differ. By month 12, there were no significant differences in the estimated marginal means of enrollment in any kind of drug treatment (0.40 and 0.27 for IM + PN and IM groups, respectively, compared to 0.29 for ETAU). There were no significant differences for either contrast in opioid-positive tests, although all groups reported a sharp decrease in heroin use from baseline to follow-up. There were five fatal overdoses, but none occurred during methadone treatment. CONCLUSION Initiating methadone treatment in jail was effective in promoting entry into community-based drug abuse treatment but subsequent treatment discontinuation attenuated any potential impact of such treatment.
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Affiliation(s)
- R.P. Schwartz
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD, USA,Corresponding author at: Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, Maryland, 21201, USA. (R.P. Schwartz)
| | - S.M. Kelly
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD, USA
| | - S.G. Mitchell
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD, USA
| | - K.E. O’Grady
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - A. Sharma
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD, USA
| | - J.H. Jaffe
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD, USA
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Fan X, Zhang X, Xu H, Yang F, Lau JT, Hao C, Li J, Zhao Y, Hao Y, Gu J. Effectiveness of a Psycho-Social Intervention Aimed at Reducing Attrition at Methadone Maintenance Treatment Clinics: A Propensity Score Matching Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16224337. [PMID: 31703302 PMCID: PMC6888175 DOI: 10.3390/ijerph16224337] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 10/30/2019] [Accepted: 11/04/2019] [Indexed: 12/16/2022]
Abstract
Methadone maintenance treatment (MMT) is an important approach to address opioid dependence. However, MMT clinics usually report high attrition rates. Our previous randomized controlled trial demonstrated additional psycho-social services delivered by social workers could reduce attrition rates compared to MMT alone. This study aimed to evaluate the effectiveness of psycho-social service in a real-world context. A quasi-experimental design and propensity score matching was adopted. 359 clients were recruited from five MMT clinics in Guangzhou from July 2013 to April 2015. One 20-minute counseling session was offered to the control group after enrolment. The intervention group received six sessions of psycho-social services. The baseline characteristics were unbalanced between two arms in the original sample. After propensity score matching, 248 participants remained in the analysis. At month six, the intervention group had a lower attrition rate [intervention (39.5%) versus control (52.4%), P = 0.041], higher monthly income [monthly income of 1000 CNY or higher: intervention (55.9%) versus control (39.0%), P = 0.028)], higher detoxification intention score [full intention score: intervention (51.6%) versus control (32.5%), P = 0.012)], higher family support in MMT participation [intervention (77.9%) versus control (61.4%), P = 0.049)]. This study demonstrated that psycho-social services delivered by social workers can reduce MMT clients’ attrition and improve their well-being in real-world settings.
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Affiliation(s)
- Xiaoyan Fan
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou 510080, Guangdong, China; (X.F.); (X.Z.); (C.H.); (J.L.); (Y.H.)
| | - Xiao Zhang
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou 510080, Guangdong, China; (X.F.); (X.Z.); (C.H.); (J.L.); (Y.H.)
- Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang, China
| | - Huifang Xu
- Guangzhou Centre for Disease Prevention and Control, Guangzhou 510080, Guangdong, China; (H.X.); (Y.Z.)
| | - Fan Yang
- Institute for Global Health and Infectious Diseases, University of North Carolina, Project-China, Guangzhou 510080, Guangdong, China;
| | - Joseph T.F. Lau
- Centre for Medical Anthropology and Behavioural Health, Sun Yat-sen University, Guangzhou 510080, Guangdong, China;
- Centre for Health Behaviours Research, School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Chun Hao
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou 510080, Guangdong, China; (X.F.); (X.Z.); (C.H.); (J.L.); (Y.H.)
- Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou 510080, Guangdong, China
| | - Jinghua Li
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou 510080, Guangdong, China; (X.F.); (X.Z.); (C.H.); (J.L.); (Y.H.)
- Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou 510080, Guangdong, China
| | - Yuteng Zhao
- Guangzhou Centre for Disease Prevention and Control, Guangzhou 510080, Guangdong, China; (H.X.); (Y.Z.)
| | - Yuantao Hao
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou 510080, Guangdong, China; (X.F.); (X.Z.); (C.H.); (J.L.); (Y.H.)
- Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou 510080, Guangdong, China
| | - Jing Gu
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou 510080, Guangdong, China; (X.F.); (X.Z.); (C.H.); (J.L.); (Y.H.)
- Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou 510080, Guangdong, China
- Correspondence: ; Tel.: +86-136-6001-7090
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Neighbors CJ, Choi S, Healy S, Yerneni R, Sun T, Shapoval L. Age related medication for addiction treatment (MAT) use for opioid use disorder among Medicaid-insured patients in New York. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2019; 14:28. [PMID: 31238952 PMCID: PMC6593566 DOI: 10.1186/s13011-019-0215-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 05/30/2019] [Indexed: 01/17/2023]
Abstract
Background Medication for addiction treatment (MAT) has received much attention in recent years for treating individuals with opioid use disorders (OUD). However, these medications have been significantly underused among particular subgroups. In this paper, we describe the age distribution of treatment episodes for substance use disorder among Medicaid beneficiaries in New York and corresponding MAT use. Methods Using New York Medicaid claims, we identified individuals with OUD that received treatment for substance use disorder in 2015. The type of substance use treatment is the primary outcome measure, which includes methadone, buprenorphine, naltrexone or other non-medication treatment. Results A total of 88,637 individuals were diagnosed with OUD and received treatment for substance use disorder and 56,926 individuals received some type of MAT in 2015, with 40.2% receiving methadone, 21.9% receiving buprenorphine and 2.2% receiving naltrexone while 21.9% received non-medication based treatment. Young adults (ages 18–29) were a large proportion (25%) of individuals in treatment for OUD yet were the least likely to receive MAT. Relative to young adults, 30–39 year olds (adjusted odds ratio [AOR] = 1.62, 95% CI = 1.56–1.68), 40–49 year olds (AOR = 1.90, 95% CI = 1.82–1.99), 50–59 year olds (AOR = 2.65, 95% CI = 2.52–2.78), and 60–64 year olds (AOR = 5.03, 95% CI = 4.62–5.48) were more likely to receive MAT. Conclusions These preliminary findings highlight high numbers of young adults in treatment for OUD and low rates of MAT, which is not consistent with treatment guidelines. Significant differences exist in the type of medication prescribed across age. More attention is needed to address the treatment needs among individuals of different age, notably young adults.
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Affiliation(s)
| | - Sugy Choi
- Center on Addiction, New York, NY, USA.,Boston University School of Public Health, Boston, MA, USA
| | | | | | - Tong Sun
- New York State Office of Alcoholism and Substance Abuse Services (OASAS), Albany, NY, USA
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23
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Lister JJ, Brown S, Greenwald MK, Ledgerwood DM. Gender-specific predictors of methadone treatment outcomes among African Americans at an urban clinic. Subst Abus 2019; 40:185-193. [PMID: 30888262 DOI: 10.1080/08897077.2018.1547810] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background: African American patients with opioid use disorder (OUD) have demonstrated poorer methadone maintenance treatment (MMT) outcomes compared with white patients. This issue is further complicated in urban settings, where African Americans experience high rates of poverty and publicly funded treatment. Despite interrelated factors that disadvantage African Americans, the literature focusing on this population is scant. To address this shortcoming, we conducted the first investigation of gender differences and gender-specific MMT outcome predictors among African Americans (or any racial minority population). This study provides gender-specific findings to improve African American MMT outcomes. Methods: We studied 211 African American patients (male: n = 137, 64.9%) at an urban, university-affiliated MMT clinic. We used existing intake data to assess baseline demographic, substance use, mental health, and interpersonal factors. Primary outcomes were 3-month drug+ (positive) urine drug screen (UDS) results and treatment retention. Results: Women were more likely (than men) to endorse histories of interpersonal violence, substance abuse in their social network, and mental health problems. Men reported a greater likelihood (than women) for early opioid-use onset and a lack of prior MMT. There were no gender differences in 3-month drug+ UDS or treatment retention. In multivariable analyses among women, no baseline factors predicted 3-month opioid+ UDS and physical abuse history predicted a higher proportion of 3-month cocaine+ UDS. Among men, primary injection opioid use and older age best predicted a higher proportion of 3-month cocaine+ UDS and parent substance abuse predicted shorter retention. In both gender-stratified analyses, higher proportions of 3-month opioid+ UDS and cocaine+ UDS predicted shorter retention. Conclusions: This study offers an analysis of gender differences in risk factors, MMT outcomes, and gender-specific predictors among African American patients. MMT clinics should tailor assessment and treatment protocols to address gender-specific needs.
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Affiliation(s)
- Jamey J Lister
- School of Social Work, Wayne State University , Detroit , Michigan , USA.,Substance Abuse Research Division, Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine , Detroit , Michigan , USA
| | - Suzanne Brown
- School of Social Work, Wayne State University , Detroit , Michigan , USA
| | - Mark K Greenwald
- Substance Abuse Research Division, Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine , Detroit , Michigan , USA.,Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University , Detroit , Michigan , USA
| | - David M Ledgerwood
- Substance Abuse Research Division, Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine , Detroit , Michigan , USA
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Sofuoglu M, DeVito EE, Carroll KM. Pharmacological and Behavioral Treatment of Opioid Use Disorder. PSYCHIATRIC RESEARCH AND CLINICAL PRACTICE 2018. [PMCID: PMC9175946 DOI: 10.1176/appi.prcp.20180006] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective: Opioid use disorder (OUD) in the United States has surged, with an estimated 2.5 million needing treatment. The aim of this article is to provide a clinical overview of the key pharmacological and behavioral treatments for OUD. Methods: A nonsystematic review of the literature was conducted to investigate OUD treatments, including their mechanism of action, efficacy, clinical guidelines in the United States, and consideration of frequently occurring comorbid conditions. Results: Food and Drug Administration (FDA)–approved pharmacotherapies for OUD include methadone, buprenorphine, and naltrexone, each of which has different actions on opioid receptors. Although these medications all show efficacy in some dosages and formulations, barriers to accessibility may be most pronounced for methadone, whereas treatment retention poses greater challenges for naltrexone and, to a lesser extent, buprenorphine. Lofexidine, an α2‐adrenergic agonist, has recently been approved by the FDA for treatment of opioid withdrawal symptoms. OUD is commonly treated with medication‐assisted treatment (MAT), which offers pharmacotherapy in the context of counseling and/or behavioral treatments. Behavioral therapies, rarely offered as stand‐alone treatments for OUD, are generally used in the context of MAT, in structured settings or to prevent relapse after detoxification and stabilization. The aim of behavioral interventions is to improve medication compliance and target problems not addressed with medication alone. Individuals with OUD commonly have other comorbid psychiatric and substance use conditions, which are not exclusionary for initiating MAT but should be carefully evaluated and monitored because they may reduce treatment effectiveness. Conclusions: MAT is the first‐line treatment for patients with OUD and should be provided in combination with behavioral interventions. Treatment retention remains challenging in this population. Future studies should focus on approaches that will serve the complex needs of patients with OUD, including those with comorbid psychiatric and substance use conditions.
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Affiliation(s)
- Mehmet Sofuoglu
- Yale University School of MedicineDepartment of Psychiatry
- VA Connecticut Healthcare SystemWest HavenCT
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Streck JM, Ochalek TA, Badger GJ, Sigmon SC. Interim buprenorphine treatment during delays to comprehensive treatment: Changes in psychiatric symptoms. Exp Clin Psychopharmacol 2018; 26:403-409. [PMID: 29939049 PMCID: PMC6072576 DOI: 10.1037/pha0000199] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Prevalence of depression, anxiety, and mood disorders among individuals with opioid use disorder far exceeds that of the general population. While psychiatric symptoms often improve upon entry into opioid treatment, this has typically been seen with treatments involving psychosocial counseling. In this secondary analysis, we examined changes in psychiatric symptoms during a randomized clinical trial evaluating an interim buprenorphine treatment without counseling among individuals awaiting entry into comprehensive treatment. Waitlisted adults with opioid use disorder (N = 50) were randomized to one of two 12-week conditions: interim buprenorphine treatment (IBT; n = 25) consisting of buprenorphine maintenance using a computerized medication dispenser, with bimonthly clinic visits and technology-assisted monitoring, or waitlist control (WLC; n = 25), wherein participants remained on the waitlist of their local clinic. All participants completed assessments of psychiatric symptoms at intake and Study Weeks 4, 8, and 12. We examined changes on the Beck Anxiety Inventory (BAI), Beck Depression Inventory-II (BDI-II), Brief Symptom Inventory (BSI), and Psychiatric subscale of the Addiction Severity Index (ASI). Significant group-by-time interactions were observed for all measures of psychiatric severity examined: BAI (p < .05), BDI-II (p < .01), 5 BSI subscales (ps < .05), and the ASI Psychiatric subscale (p < .05). On all measures, IBT participants reported significantly reduced psychiatric severity at the 4-, 8-, and 12-week assessments relative to baseline. In contrast, there were no significant changes in psychiatric symptoms among WLC participants. IBT without counseling may improve psychiatric distress among waitlisted individuals with opioid use disorder. (PsycINFO Database Record
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Affiliation(s)
- Joanna M. Streck
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT, USA
- Department of Psychological Science, University of Vermont, Burlington, VT, USA
| | - Taylor A. Ochalek
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT, USA
- Department of Psychological Science, University of Vermont, Burlington, VT, USA
| | - Gary J. Badger
- Department of Medical Biostatistics, University of Vermont, Burlington, VT, USA
| | - Stacey C. Sigmon
- Vermont Center on Behavior and Health, University of Vermont, Burlington, VT, USA
- Department of Psychological Science, University of Vermont, Burlington, VT, USA
- Department of Psychiatry, University of Vermont, Burlington, VT, USA
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Rahimi‐Movaghar A, Gholami J, Amato L, Hoseinie L, Yousefi‐Nooraie R, Amin‐Esmaeili M. Pharmacological therapies for management of opium withdrawal. Cochrane Database Syst Rev 2018; 6:CD007522. [PMID: 29929212 PMCID: PMC6513031 DOI: 10.1002/14651858.cd007522.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Pharmacologic therapies for management of heroin withdrawal have been studied and reviewed widely. Opium dependence is generally associated with less severe dependence and milder withdrawal symptoms than heroin. The evidence on withdrawal management of heroin might therefore not be exactly applicable for opium. OBJECTIVES To assess the effectiveness and safety of various pharmacologic therapies for the management of the acute phase of opium withdrawal. SEARCH METHODS We searched the following sources up to September 2017: CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, regional and national databases (IMEMR, Iranmedex, and IranPsych), main electronic sources of ongoing trials, and reference lists of all relevant papers. In addition, we contacted known investigators to obtain missing data or incomplete trials. SELECTION CRITERIA Controlled clinical trials and randomised controlled trials on pharmacological therapies, compared with no intervention, placebo, other pharmacologic treatments, different doses of the same drug, and psychosocial intervention, to manage acute withdrawal from opium in a maximum duration of 30 days. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. MAIN RESULTS We included 13 trials involving 1096 participants. No pooled analysis was possible. Studies were carried out in three countries, Iran, India, and Thailand, in outpatient and inpatient settings. The quality of the evidence was generally very low.When the mean of withdrawal symptoms was provided for several days, we mainly focused on day 3. The reason for this was that the highest severity of opium withdrawal is in the second to fourth day.Comparing different pharmacological treatments with each other, clonidine was twice as good as methadone for completion of treatment (risk ratio (RR) 2.01, 95% confidence interval (CI) 1.69 to 2.38; 361 participants, 1 study, low-quality evidence). All the other results showed no differences between the considered drugs: baclofen versus clonidine (RR 1.06, 95% CI 0.63 to 1.80; 66 participants, 1 study, very low-quality evidence); clonidine versus clonidine plus amantadine (RR 1.03, 95% CI 0.86 to 1.24; 69 participants, 1 study); clonidine versus buprenorphine in an inpatient setting (RR 1.04, 95% CI 0.90 to 1.20; 1 study, 35 participants, very low-quality evidence); methadone versus tramadol (RR 0.95, 95% CI 0.65 to 1.37; 1 study, 72 participants, very low-quality evidence); methadone versus methadone plus gabapentin (RR 1.17, 95% CI 0.96 to 1.43; 1 study, 40 participants, low-quality evidence), and tincture of opium versus methadone (1 study, 74 participants, low-quality evidence).Comparing different pharmacological treatments with each other, adding amantadine to clonidine decreased withdrawal scores rated at day 3 (mean difference (MD) -3.56, 95% CI -5.97 to -1.15; 1 study, 60 participants, very low-quality evidence). Comparing clonidine with buprenorphine in an inpatient setting, we found no difference in withdrawal symptoms rated by a physician (MD -1.40, 95% CI -2.93 to 0.13; 1 study, 34 participants, very low-quality evidence), and results in favour of buprenorpine when rated by participants (MD -11.80, 95% CI -15.56 to -8.04). Buprenorphine was superior to clonidine in controlling severe withdrawal symptoms in an outpatient setting (RR 0.35, 95% CI 0.19 to 0.64; 1 study, 76 participants). We found no difference in the comparison of methadone versus tramadol (MD 0.04, 95% CI -2.68 to 2.76; 1 study, 72 participants) and in the comparison of methadone versus methadone plus gabapentin (MD -2.20, 95% CI -6.72 to 2.32; 1 study, 40 participants).Comparing clonidine versus buprenorphine in an outpatient setting, more adverse effects were reported in the clonidine group (1 study, 76 participants). Higher numbers of participants in the clonidine group experienced hypotension at days 5 to 8, headache at days 1 to 8, sedation at days 5 to 8, dizziness and dry mouth at days 1 to 10, and nausea at days 1 to 9. Sweating was reported in a significantly higher number of participants in the buprenorphine group at days 1 to 10. We found no difference between groups for all the other comparisons considering this outcome.Comparing different dosages of the same pharmacological detoxification treatment, a high dose of clonidine (1 to 1.2 mg/day) did not differ from a low dose of clonidine (0.5 to 0.6 mg/day) in completion of treatment in an inpatient setting (RR 1.00, 95% CI 0.84 to 1.19; 1 study, 68 participants), however a higher number of participants with hypotension was reported in the high-dose group (RR 3.25, 95% CI 1.77 to 5.98). Gradual reduction of methadone was associated with more adverse effects than abrupt withdrawal of methadone (RR 2.25, 95% CI 1.02 to 4.94; 1 study, 20 participants, very low-quality evidence). AUTHORS' CONCLUSIONS Results did not support using any specific pharmacological approach for the management of opium withdrawal due to generally very low-quality evidence and small or no differences between treatments. However, it seems that opium withdrawal symptoms are significant, especially at days 2 to 4 after discontinuation of opium. All of the assessed medications might be useful in alleviating symptoms. Those who receive clonidine might experience hypotension.
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Affiliation(s)
- Afarin Rahimi‐Movaghar
- Tehran University of Medical SciencesIranian National Center for Addiction Studies (INCAS)No. 486, South Karegar Ave.TehranTehranIran1336616357
| | - Jaleh Gholami
- Tehran University of Medical SciencesIranian National Center for Addiction Studies (INCAS)No. 486, South Karegar Ave.TehranTehranIran1336616357
| | - Laura Amato
- Lazio Regional Health ServiceDepartment of EpidemiologyVia Cristoforo Colombo, 112RomeItaly00154
| | - Leila Hoseinie
- Tehran University of Medical SciencesIranian National Center for Addiction Studies (INCAS)No. 486, South Karegar Ave.TehranTehranIran1336616357
| | - Reza Yousefi‐Nooraie
- University of TorontoInstitute of Health Policy, Management and Evaluation155 College StreetTorontoONCanadaM5T 3M6
| | - Masoumeh Amin‐Esmaeili
- Tehran University of Medical SciencesIranian National Center for Addiction Studies (INCAS)No. 486, South Karegar Ave.TehranTehranIran1336616357
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Kidorf M, Brooner RK, Leoutsakos JM, Peirce J. Treatment initiation strategies for syringe exchange referrals to methadone maintenance: A randomized clinical trial. Drug Alcohol Depend 2018; 187:343-350. [PMID: 29709732 DOI: 10.1016/j.drugalcdep.2018.03.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 03/08/2018] [Accepted: 03/09/2018] [Indexed: 11/26/2022]
Abstract
This randomized clinical trial evaluated the efficacy of three treatment initiation strategies for improving retention to methadone maintenance for opioid-dependent individuals referred from a syringe exchange program (SEP). New admissions (n = 212) were randomly assigned to one of three 3-month initiation strategies: 1) Low Threshold (LTI), 2) Voucher Reinforcement (VRI), or 3) Standard Care (SCI). LTI was modeled on interim methadone maintenance to transition SEP admissions to the structure of medication-assisted treatment while maximizing exposure to methadone pharmacotherapy. VRI used monetary incentives to reinforce adherence to pharmacotherapy and adaptive counseling. SCI participants received standard methadone dosing and adaptive counseling. All participants were stabilized on methadone pharmacotherapy with a target dose of 80 mg. Following the initiation phase, participants in each condition received standard adaptive counseling from months 4-6. Results showed that most participants failed to achieve the target methadone dose. While no condition differences were observed in retention rates over the 3-month and 6-month observation periods, participants across conditions exhibited reductions in objective and self-report measures of drug use. Results support the benefits of referring syringe exchangers to methadone maintenance, and demonstrate the challenge of retaining these individuals in treatment.
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Affiliation(s)
- Michael Kidorf
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Addiction Treatment Services - BBRC, Johns Hopkins Bayview Medical Center, 5510 Nathan Shock Drive, Suite 1500, Baltimore, MD, 21224, United States.
| | - Robert K Brooner
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Addiction Treatment Services - BBRC, Johns Hopkins Bayview Medical Center, 5510 Nathan Shock Drive, Suite 1500, Baltimore, MD, 21224, United States
| | - Jeannie-Marie Leoutsakos
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Addiction Treatment Services - BBRC, Johns Hopkins Bayview Medical Center, 5510 Nathan Shock Drive, Suite 1500, Baltimore, MD, 21224, United States
| | - Jessica Peirce
- Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Addiction Treatment Services - BBRC, Johns Hopkins Bayview Medical Center, 5510 Nathan Shock Drive, Suite 1500, Baltimore, MD, 21224, United States
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When Added to Opioid Agonist Treatment, Psychosocial Interventions do not Further Reduce the Use of Illicit Opioids: A Comment on Dugosh et al. J Addict Med 2017; 10:283-5. [PMID: 27471920 DOI: 10.1097/adm.0000000000000236] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This commentary reviews the limitations of the recent literature review by that examined the role of psychosocial interventions with medication for opioid addiction treatment. The commonly held belief that opioid agonist treatment alone is inferior treatment to such treatment combined with 'psychosocial' treatment (which many will understand to mean counseling) is not supported by the research evidence and it results in limitations on the use of these effective medications.
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Day E, Mitcheson L. Psychosocial interventions in opiate substitution treatment services: does the evidence provide a case for optimism or nihilism? Addiction 2017; 112:1329-1336. [PMID: 28044376 DOI: 10.1111/add.13644] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 09/20/2016] [Accepted: 10/05/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIMS Clinical guidelines from around the world recommend the delivery of psychosocial interventions as part of routine care in opiate substitution treatment (OST) programmes. However, although individual studies demonstrate benefit for structured psychosocial interventions, meta-analytical reviews find no benefit for manual-based treatments beyond 'routine counselling'. ANALYSIS We consider the question of whether OST medication alone is sufficient to produce the required outcomes, or whether greater efforts should be made to provide high-quality psychosocial treatment alongside medication. In so doing, we consider the nuances and limitations of the evidence and the organizational barriers to transferring it into routine practice. CONCLUSION The evidence base for psychosocial interventions in opiate substitution treatment (OST) services can be interpreted both positively and negatively. Steering a path between overly optimistic or nihilistic interpretations of the value of psychosocial treatment in OST programmes is the most pragmatic approach. Greater attention should be paid to elements common to all psychological treatments (such as therapeutic alliance), but also to the sequencing and packaging of psychosocial elements and their linkage to peer-led interventions.
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Affiliation(s)
- Ed Day
- Addictions Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Solihull Integrated Addiction Service, Solihull, UK
| | - Luke Mitcheson
- South London and Maudsley NHS Foundation Trust, London, UK
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Abstract
OBJECTIVE Although counseling is a required part of office-based buprenorphine treatment of opioid use disorders, the nature of what constitutes appropriate counseling is unclear and controversial. The authors review the literature on the role, nature, and intensity of behavioral interventions in office-based buprenorphine treatment. METHOD The authors conducted a review of randomized controlled studies testing the efficacy of adding a behavioral intervention to buprenorphine maintenance treatment. RESULTS Four key studies showed no benefit from adding a behavioral intervention to buprenorphine plus medical management, and four studies indicated some benefit for specific behavioral interventions, primarily contingency management. The authors examined the findings from the negative trials in the context of six questions: 1) Is buprenorphine that effective? 2) Is medical management that effective? 3) Are behavioral interventions that ineffective in this population? 4) How has research design affected the results of studies of buprenorphine plus behavioral treatment? 5) What do we know about subgroups of patients who do and those who do not seem to benefit from behavioral interventions? 6) What should clinicians aim for in terms of treatment outcome in buprenorphine maintenance? CONCLUSIONS High-quality medical management may suffice for some patients, but there are few data regarding the types of individuals for whom medical management is sufficient. Physicians should consider a stepped-care model in which patients may begin with relatively nonintensive treatment, with increased intensity for patients who struggle early in treatment. Finally, with 6-month retention rates seldom exceeding 50% and poor outcomes following dropout, we must explore innovative strategies for enhancing retention in buprenorphine treatment.
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Affiliation(s)
- Kathleen M. Carroll
- Department of Psychiatry, Yale University School of Medicine, 950 Campbell Avenue, MIRECC 151D, West Haven, CT 06516, 203-932-5711 x 7403,
| | - Roger D. Weiss
- Division of Alcohol and Drug Abuse, McLean Hospital, 115 Mill St. Belmont, MA 02478, 617-855-2242, , Department of Psychiatry, Harvard Medical School, Boston, MA 02215
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The Prescription Opioid Addiction Treatment Study: What have we learned. Drug Alcohol Depend 2017; 173 Suppl 1:S48-S54. [PMID: 28363320 PMCID: PMC6866670 DOI: 10.1016/j.drugalcdep.2016.12.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 12/16/2016] [Accepted: 12/17/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND The multi-site Prescription Opioid Addiction Treatment Study (POATS), conducted by the National Drug Abuse Treatment Clinical Trials Network, was the largest clinical trial yet conducted with patients dependent upon prescription opioids (N=653). In addition to main trial results, the study yielded numerous secondary analyses, and included a 3.5-year follow-up study, the first of its kind with this population. This paper reviews key findings from POATS and its follow-up study. METHODS The paper summarizes the POATS design, main outcomes, predictors of outcome, subgroup analyses, the predictive power of early treatment response, and the long-term follow-up study. RESULTS POATS examined combinations of buprenorphine-naloxone of varying duration and counseling of varying intensity. The primary outcome analysis showed no overall benefit to adding drug counseling to buprenorphine-naloxone and weekly medical management. Only 7% of patients achieved a successful outcome (abstinence or near-abstinence from opioids) during a 4-week taper and 8-week follow-up; by comparison, 49% of patients achieved success while subsequently stabilized on buprenorphine-naloxone. Long-term follow-up results were more encouraging, with higher abstinence rates than in the main trial. Patients receiving opioid agonist treatment at the time of follow-up were more likely to have better outcomes, though a sizeable number of patients succeeded without agonist treatment. Some patients initiated risky use patterns, including heroin use and drug injection. A limitation of the long-term follow-up study was the low follow-up rate. CONCLUSIONS POATS was the first large-scale study of the treatment of prescription opioid dependence; its findings can influence both treatment guidelines and future studies.
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Some Additional Considerations Regarding the American Society of Addiction Medicine National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. J Addict Med 2017; 10:140-2. [PMID: 27223833 DOI: 10.1097/adm.0000000000000219] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ramsey SE, Rounsaville D, Hoskinson R, Park TW, Ames EG, Neirinckx VD, Friedmann P. The Need for Psychosocial Interventions to Facilitate the Transition to Extended-Release Naltrexone (XR-NTX) Treatment for Opioid Dependence: A Concise Review of the Literature. SUBSTANCE ABUSE-RESEARCH AND TREATMENT 2016; 10:65-8. [PMID: 27512336 PMCID: PMC4975246 DOI: 10.4137/sart.s39067] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 06/06/2016] [Accepted: 06/06/2016] [Indexed: 11/18/2022]
Abstract
Given the increase of opioid dependence and opioid-related morbidity and mortality, improving treatment options for individuals with opioid dependence warrants increased attention. This article provides a concise review of work in this area. Remission from opioid dependence can be very difficult to sustain, particularly in the absence of opioid replacement or opioid antagonist therapy. For those who wish to transition from opioid use or opioid replacement therapy to opioid antagonist therapy, a significant challenge can be the period of withdrawal symptoms that must be endured prior to the initiation of opioid antagonist therapy. Studies that have incorporated psychosocial interventions into detoxification protocols have found that they can result in improved treatment outcomes. Interventions based on Acceptance and Commitment Therapy have shown promise in the treatment of clinical disorders that present with symptoms similar to those of opioid withdrawal and have been found to positively impact outcomes among those tapering from methadone. However, the use of an Acceptance and Commitment Therapy-based intervention has yet to be studied among opioid-dependent patients transitioning to XR-NTX, and its value to those transitioning to XR-NTX is currently unknown.
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Affiliation(s)
- Susan E Ramsey
- Rhode Island Hospital, Providence, RI, USA.; Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Providence, RI, USA.; Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | | | - Tae Woo Park
- Rhode Island Hospital, Providence, RI, USA.; Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Providence, RI, USA
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Schwartz RP, Kelly SM, Mitchell SG, Dunlap L, Zarkin GA, Sharma A, O'Grady KE, Jaffe JH. Interim methadone and patient navigation in jail: Rationale and design of a randomized clinical trial. Contemp Clin Trials 2016; 49:21-8. [PMID: 27282117 PMCID: PMC4969178 DOI: 10.1016/j.cct.2016.06.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 05/31/2016] [Accepted: 06/04/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Methadone maintenance is an effective treatment for opioid dependence but is rarely initiated in US jails. Patient navigation is a promising approach to improve continuity of care but has not been tested in bridging the gap between jail- and community-based drug treatment programs. METHODS This is an open-label randomized clinical trial among 300 adult opioid dependent newly-arrested detainees that will compare three treatment conditions: methadone maintenance without routine counseling (termed Interim Methadone; IM) initiated in jail v. IM and patient navigation v. enhanced treatment-as-usual. The two primary outcomes will be: (1) the rate of entry into treatment for opioid use disorder within 30days from release and (2) frequency of opioid positive urine tests over the 12-month follow-up period. An economic analysis will examine the costs, cost-effectiveness, and cost-benefit ratio of the study interventions. RESULTS We describe the background and rationale for the study, its aims, hypotheses, and study design. CONCLUSIONS Given the large number of opioid dependent detainees in the US and elsewhere, initiating IM at the time of incarceration could be a significant public health and clinical approach to reducing relapse, recidivism, HIV-risk behavior, and criminal behavior. An economic analysis will be conducted to assist policy makers in determining the utility of adopting this approach. ClinicalTrials.gov: NCT02334215.
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Affiliation(s)
| | | | | | - Laura Dunlap
- RTI International, Research Triangle Park, NC, USA
| | | | | | - Kevin E O'Grady
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
| | - Jerome H Jaffe
- Friends Research Institute, Baltimore, MD, USA; Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
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Nielsen S, Larance B, Degenhardt L, Gowing L, Kehler C, Lintzeris N. Opioid agonist treatment for pharmaceutical opioid dependent people. Cochrane Database Syst Rev 2016:CD011117. [PMID: 27157143 DOI: 10.1002/14651858.cd011117.pub2] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND There are increasing concerns regarding pharmaceutical opioid harms including overdose and dependence, with an associated increase in treatment demand. People dependent on pharmaceutical opioids appear to differ in important ways from people who use heroin, yet most opioid agonist treatment research has been conducted in people who use heroin. OBJECTIVES To assess the effects of maintenance agonist pharmacotherapy for the treatment of pharmaceutical opioid dependence. SEARCH METHODS The search included the Cochrane Drugs and Alcohol Group's Specialised Register of Trials; the Cochrane Central Register of Controlled Trials (CENTRAL, 2015, Issue 5); PubMed (January 1966 to May 2015); EMBASE (Ovid) (January 1974 to May 2015); CINAHL (EBSCOhost) (1982 to May 2015); ISI Web of Science (to May 2014); and PsycINFO (Ovid) (1806 to May 2014). SELECTION CRITERIA We included randomised controlled trials examining maintenance opioid agonist treatments that made the following two comparisons:1. full opioid agonists (methadone, morphine, oxycodone, levo-alpha-acetylmethadol (LAAM), or codeine) versus different full opioid agonists or partial opioid agonists (buprenorphine) for maintenance treatment and2. full or partial opioid agonist maintenance versus placebo, detoxification only, or psychological treatment (without opioid agonist treatment). DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. MAIN RESULTS We identified six randomised controlled trials that met inclusion criteria (607 participants).We found moderate quality evidence from two studies of no difference between methadone and buprenorphine in self reported opioid use (risk ratio (RR) 0.37, 95% confidence interval (CI) 0.08 to 1.63) or opioid positive urine drug tests (RR 0.81, 95% CI 0.56 to 1.18). There was low quality evidence from three studies of no difference in retention between buprenorphine and methadone maintenance treatment (RR 0.69, 95% CI 0.39 to 1.22). There was moderate quality evidence from two studies of no difference between methadone and buprenorphine on adverse events (RR 1.10, 95% CI 0.64 to 1.91).We found low quality evidence from three studies favouring maintenance buprenorphine treatment over detoxification or psychological treatment in terms of fewer opioid positive urine drug tests (RR 0.63, 95% CI 0.43 to 0.91) and self reported opioid use in the past 30 days (RR 0.54, 95% CI 0.31 to 0.93). There was no difference on days of unsanctioned opioid use (standardised mean difference (SMD) -0.31, 95% CI -0.66 to 0.04). There was moderate quality evidence favouring buprenorphine maintenance over detoxification or psychological treatment on retention in treatment (RR 0.33, 95% CI 0.23 to 0.47). There was moderate quality evidence favouring buprenorphine maintenance over detoxification or psychological treatment on adverse events (RR 0.19, 95% CI 0.06 to 0.57).The main weaknesses in the quality of the data was the use of open-label study designs. AUTHORS' CONCLUSIONS There was low to moderate quality evidence supporting the use of maintenance agonist pharmacotherapy for pharmaceutical opioid dependence. Methadone or buprenorphine appeared equally effective. Maintenance treatment with buprenorphine appeared more effective than detoxification or psychological treatments.Due to the overall low to moderate quality of the evidence and small sample sizes, there is the possibility that the further research may change these findings.
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Affiliation(s)
- Suzanne Nielsen
- National Drug and Alcohol Research Centre, UNSW, Building R3, 22 - 32 King Street, Randwick, NSW, Australia, 2031
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Chandler RK, Finger MS, Farabee D, Schwartz RP, Condon T, Dunlap LJ, Zarkin GA, McCollister K, McDonald RD, Laska E, Bennett D, Kelly SM, Hillhouse M, Mitchell SG, O'Grady KE, Lee JD. The SOMATICS collaborative: Introduction to a National Institute on Drug Abuse cooperative study of pharmacotherapy for opioid treatment in criminal justice settings. Contemp Clin Trials 2016; 48:166-72. [PMID: 27180088 PMCID: PMC5454801 DOI: 10.1016/j.cct.2016.05.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 05/06/2016] [Accepted: 05/09/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Among the nearly 750,000 inmates in U.S. jails, 12% report using opioids regularly, 8% report use in the month prior to their offense, and 4% report use at the time of their offense. Although ample evidence exists that medications effectively treat Opiate Use Disorder (OUD) in the community, strong evidence is lacking in jail settings. The general lack of medications for OUD in jail settings may place persons suffering from OUD at high risk for relapse to drug use and overdose following release from jail. METHODS The three study sites in this collaborative are pooling data for secondary analyses from three open-label randomized effectiveness trials comparing: (1) the initiation of extended-release naltrexone [XR-NTX] in Sites 1 and 2 and interim methadone in Site 3 with enhanced treatment-as usual (ETAU); (2) the additional benefit of patient navigation plus medications at Sites 2 and 3 vs. medication alone vs. ETAU. Participants are adults with OUD incarcerated in jail and transitioning to the community. RESULTS We describe the rationale, specific aims, and designs of three separate studies harmonized to enhance their scientific yield to investigate how to best prevent jail inmates from relapsing to opioid use and associated problems as they transition back to the community. CONCLUSIONS Conducting drug abuse research during incarceration is challenging and study designs with data harmonization across different sites can increase the potential value of research to develop effective treatments for individuals in jail with OUD.
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Affiliation(s)
- Redonna K Chandler
- Division of Epidemiology, Services and Prevention Research, National Institute on Drug Abuse, National Institutes of Health, United States.
| | - Matthew S Finger
- Division of Epidemiology, Services and Prevention Research, National Institute on Drug Abuse, National Institutes of Health, United States
| | - David Farabee
- UCLA Integrated Substance Abuse Programs Department of Psychiatry & Biobehavioral Sciences, University of California, Los Angeles, United States
| | | | - Timothy Condon
- Center on Alcoholism, Substance Abuse, and Addictions, The University of New Mexico, United States
| | - Laura J Dunlap
- RTI International, Research Triangle Park, NC, United States
| | - Gary A Zarkin
- RTI International, Research Triangle Park, NC, United States
| | | | - Ryan D McDonald
- Department of Population Health, NYU School of Medicine, United States
| | - Eugene Laska
- Department of Psychiatry, NYU School of Medicine, United States
| | - David Bennett
- UCLA Integrated Substance Abuse Programs Department of Psychiatry & Biobehavioral Sciences, University of California, Los Angeles, United States
| | - Sharon M Kelly
- Friends Research Institute, Baltimore, MD, United States
| | - Maureen Hillhouse
- UCLA Integrated Substance Abuse Programs Department of Psychiatry & Biobehavioral Sciences, University of California, Los Angeles, United States
| | | | - Kevin E O'Grady
- University of Maryland, College Park, College Park, MD, United States
| | - Joshua D Lee
- Department of Population Health, NYU School of Medicine, United States
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Dugosh K, Abraham A, Seymour B, McLoyd K, Chalk M, Festinger D. A Systematic Review on the Use of Psychosocial Interventions in Conjunction With Medications for the Treatment of Opioid Addiction. J Addict Med 2016; 10:93-103. [PMID: 26808307 PMCID: PMC4795974 DOI: 10.1097/adm.0000000000000193] [Citation(s) in RCA: 181] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 12/06/2015] [Indexed: 11/26/2022]
Abstract
Opioid use and overdose rates have risen to epidemic levels in the United States during the past decade. Fortunately, there are effective medications (ie, methadone, buprenorphine, and oral and injectable naltrexone) available for the treatment of opioid addiction. Each of these medications is approved for use in conjunction with psychosocial treatment; however, there is a dearth of empirical research on the optimal psychosocial interventions to use with these medications. In this systematic review, we outline and discuss the findings of 3 prominent prior reviews and 27 recent publications of empirical studies on this topic. The most widely studied psychosocial interventions examined in conjunction with medications for opioid addiction were contingency management and cognitive behavioral therapy, with the majority focusing on methadone treatment. The results generally support the efficacy of providing psychosocial interventions in combination with medications to treat opioid addictions, although the incremental utility varied across studies, outcomes, medications, and interventions. The review highlights significant gaps in the literature and provides areas for future research. Given the enormity of the current opioid problem in the United States, it is critical to gain a better understanding of the most effective ways to deliver psychosocial treatments in conjunction with these medications to improve the health and well-being of individuals suffering from opioid addiction.
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Affiliation(s)
- Karen Dugosh
- Treatment Research Institute, Philadelphia, PA (KD, AA, BS, KML, MC, DF); Department of Health Policy and Management, University of Georgia, Athens, GA (AA)
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Davis JP, Smith DC, Morphew JW, Lei X, Zhang S. Cannabis Withdrawal, Posttreatment Abstinence, and Days to First Cannabis Use Among Emerging Adults in Substance Use Treatment: A Prospective Study. JOURNAL OF DRUG ISSUES 2016; 46:64-83. [PMID: 26877548 PMCID: PMC4748964 DOI: 10.1177/0022042615616431] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Very little prospective research investigates how cannabis withdrawal is associated with treatment outcomes, and this work has not used the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) thresholds for cannabis withdrawal. The sample included 110 emerging adults entering outpatient substance use treatment who were heavy cannabis users with no other drug use and limited alcohol use. We used survival analyses to predict days to first use of cannabis and logistic regression to predict whether participants were abstinent and living in the community at 3 months. Those meeting criteria for cannabis withdrawal were more likely to return to use sooner than those not meeting criteria for cannabis withdrawal. However, the presence of cannabis withdrawal was not a significant predictor of 3-month abstinence. Emerging adults with DSM-5 cannabis withdrawal may have difficulty initiating abstinence in the days following their intake assessment, implying the need for strategies to mitigate their more rapid return to cannabis use.
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Affiliation(s)
| | | | | | - Xinrong Lei
- University of Illinois at Urbana–Champaign, Urbana, IL, USA
| | - Saijun Zhang
- University of Illinois at Urbana–Champaign, Urbana, IL, USA
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Sigmon SC, C. Meyer A, Hruska B, Ochalek T, Rose G, Badger GJ, Brooklyn JR, Heil SH, Higgins ST, Moore BA, Schwartz RP. Bridging waitlist delays with interim buprenorphine treatment: initial feasibility. Addict Behav 2015; 51:136-42. [PMID: 26256469 DOI: 10.1016/j.addbeh.2015.07.030] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 07/02/2015] [Accepted: 07/27/2015] [Indexed: 10/23/2022]
Abstract
Despite the effectiveness of agonist maintenance for opioid dependence, individuals can remain on waitlists for months, during which they are at significant risk for morbidity and mortality. Interim dosing, consisting of daily medication without counseling, can reduce these risks. In this pilot study, we examined the initial feasibility of a novel technology-assisted interim buprenorphine treatment for waitlisted opioid-dependent adults. Following buprenorphine induction during Week 1, participants (n=10) visited the clinic at Weeks 2, 4, 6, 8, 10 and 12 to ingest their medication under staff observation, provide a urine specimen and receive their remaining doses via a computerized Med-O-Wheel Secure device. They also received daily monitoring via an Interactive Voice Response (IVR) platform, as well as random call-backs for urinalysis and medication adherence checks. The primary outcome was percent of participants negative for illicit opioids at each 2-week visit, with secondary outcomes of past-month drug use, adherence and acceptability. Participants achieved high levels of illicit opioid abstinence, with 90% abstinent at the Week 2 and 4 visits and 60% at Week 12. Significant reductions were observed in self-reported past-month illicit opioid use (p<.001), opioid withdrawal (p<.001), opioid craving (p<.001) and ASI Drug composite score (p=.008). Finally, adherence with buprenorphine administration (99%), daily IVR calls (97%) and random call-backs (82%) was high. Interim buprenorphine treatment shows promise for reducing patient and societal risks during delays to conventional treatment. A larger-scale, randomized clinical trial is underway to more rigorously examine the efficacy of this treatment approach.
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Sigmon SC. Interim treatment: Bridging delays to opioid treatment access. Prev Med 2015; 80:32-6. [PMID: 25937593 PMCID: PMC4592374 DOI: 10.1016/j.ypmed.2015.04.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 04/16/2015] [Accepted: 04/26/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Despite the undisputed effectiveness of agonist maintenance for opioid dependence, individuals can remain on waitlists for months, during which they are at significant risk for morbidity and mortality. To mitigate these risks, the Food and Drug Administration in 1993 approved interim treatment, involving daily medication+emergency counseling only, when only a waitlist is otherwise available. We review the published research in the 20years since the approval of interim opioid treatment. METHODS A literature search was conducted to identify all randomized trials evaluating the efficacy of interim treatment for opioid-dependent patients awaiting comprehensive treatment. RESULTS Interim opioid treatment has been evaluated in four controlled trials to date. In three, interim treatment was compared to waitlist or placebo control conditions and produced greater outcomes on measures of illicit opioid use, retention, criminality, and likelihood of entry into comprehensive treatment. In the fourth, interim treatment was compared to standard methadone maintenance and produced comparable outcomes in illicit opioid use, retention, and criminal activity. CONCLUSIONS Interim treatment significantly reduces patient and societal risks when conventional treatment is unavailable. Further research is needed to examine the generality of these findings, further enhance outcomes, and identify the patient characteristics which predict treatment response.
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Affiliation(s)
- Stacey C Sigmon
- Department of Psychiatry, University of Vermont College of Medicine, Vermont Center on Behavior and Health, USA.
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Rich JD, McKenzie M, Larney S, Wong JB, Tran L, Clarke J, Noska A, Reddy M, Zaller N. Methadone continuation versus forced withdrawal on incarceration in a combined US prison and jail: a randomised, open-label trial. Lancet 2015; 386:350-9. [PMID: 26028120 PMCID: PMC4522212 DOI: 10.1016/s0140-6736(14)62338-2] [Citation(s) in RCA: 145] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Methadone is an effective treatment for opioid dependence. When people who are receiving methadone maintenance treatment for opioid dependence are incarcerated in prison or jail, most US correctional facilities discontinue their methadone treatment, either gradually, or more often, abruptly. This discontinuation can cause uncomfortable symptoms of withdrawal and renders prisoners susceptible to relapse and overdose on release. We aimed to study the effect of forced withdrawal from methadone upon incarceration on individuals' risk behaviours and engagement with post-release treatment programmes. METHODS In this randomised, open-label trial, we randomly assigned (1:1) inmates of the Rhode Island Department of Corrections (RI, USA) who were enrolled in a methadone maintenance-treatment programme in the community at the time of arrest and wanted to remain on methadone treatment during incarceration and on release, to either continuation of their methadone treatment or to usual care--forced tapered withdrawal from methadone. Participants could be included in the study only if their incarceration would be more than 1 week but less than 6 months. We did the random assignments with a computer-generated random permutation, and urn randomisation procedures to stratify participants by sex and race. Participants in the continued-methadone group were maintained on their methadone dose at the time of their incarceration (with dose adjustments as clinically indicated). Patients in the forced-withdrawal group followed the institution's standard withdrawal protocol of receiving methadone for 1 week at the dose at the time of their incarceration, then a tapered withdrawal regimen (for those on a starting dose >100 mg, the dose was reduced by 5 mg per day to 100 mg, then reduced by 3 mg per day to 0 mg; for those on a starting dose >100 mg, the dose was reduced by 3 mg per day to 0 mg). The main outcomes were engagement with a methadone maintenance-treatment clinic after release from incarceration and time to engagement with methadone maintenance treatment, by intention-to-treat and as-treated analyses, which we established in a follow-up interview with the participants at 1 month after their release from incarceration. Our study paid for 10 weeks of methadone treatment after release if participants needed financial help. This trial is registered with ClinicalTrials.gov, number NCT01874964. FINDINGS Between June 14, 2011, and April 3, 2013, we randomly assigned 283 prisoners to our study, 142 to continued methadone treatment, and 141 to forced withdrawal from methadone. Of these, 60 were excluded because they did not fit the eligibility criteria, leaving 114 in the continued-methadone group and 109 in the forced-withdrawal group (usual care). Participants assigned to continued methadone were more than twice as likely than forced-withdrawal participants to return to a community methadone clinic within 1 month of release (106 [96%] of 110 in the continued-methadone group compared with 68 [78%] of 87 in the forced-withdrawal group; adjusted hazard ratio [HR] 2·04, 95% CI 1·48-2·80). We noted no differences in serious adverse events between groups. For the continued-methadone and forced-withdrawal groups, the number of deaths were one and zero, non-fatal overdoses were one and two, admissions to hospital were one and four; and emergency-room visits were 11 and 16, respectively. INTERPRETATION Although our study had several limitations--eg, it only included participants incarcerated for fewer than 6 months, we showed that forced withdrawal from methadone on incarceration reduced the likelihood of prisoners re-engaging in methadone maintenance after their release. Continuation of methadone maintenance during incarceration could contribute to greater treatment engagement after release, which could in turn reduce the risk of death from overdose and risk behaviours. FUNDING National Institute on Drug Abuse and the Lifespan/Tufts/Brown Center for AIDS Research from the National Institutes of Health.
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Affiliation(s)
- Josiah D Rich
- Brown University, Providence, RI, USA; The Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA.
| | - Michelle McKenzie
- Brown University, Providence, RI, USA; The Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA
| | - Sarah Larney
- Brown University, Providence, RI, USA; The Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA; National Drug and Alcohol Research Centre, University of New South Wales, NSW, Australia
| | - John B Wong
- Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Liem Tran
- The Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA
| | - Jennifer Clarke
- Brown University, Providence, RI, USA; The Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA; Memorial Hospital, Pawtucket, RI, USA
| | - Amanda Noska
- Brown University, Providence, RI, USA; The Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA
| | - Manasa Reddy
- Brown University, Providence, RI, USA; The Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA
| | - Nickolas Zaller
- Fay W Boozman College of Public Health, University of Arkansas for Medical Sciences, AR, USA; The Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA
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White WL. Congress 60: An Addiction Recovery Community within the Islamic Republic of Iran. ALCOHOLISM TREATMENT QUARTERLY 2015. [DOI: 10.1080/07347324.2015.1050929] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Northrup TF, Stotts AL, Green C, Potter JS, Marino EN, Walker R, Weiss RD, Trivedi M. Opioid withdrawal, craving, and use during and after outpatient buprenorphine stabilization and taper: a discrete survival and growth mixture model. Addict Behav 2015; 41:20-8. [PMID: 25282598 DOI: 10.1016/j.addbeh.2014.09.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 06/30/2014] [Accepted: 09/17/2014] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Most patients relapse to opioids within one month of opioid agonist detoxification, making the antecedents and parallel processes of first use critical for investigation. Craving and withdrawal are often studied in relationship to opioid outcomes, and a novel analytic strategy applied to these two phenomena may indicate targeted intervention strategies. METHODS Specifically, this secondary data analysis of the Prescription Opioid Addiction Treatment Study used a discrete-time mixture analysis with time-to-first opioid use (survival) simultaneously predicted by craving and withdrawal growth trajectories. This analysis characterized heterogeneity among prescription opioid-dependent individuals (N=653) into latent classes (i.e., latent class analysis [LCA]) during and after buprenorphine/naloxone stabilization and taper. RESULTS A 4-latent class solution was selected for overall model fit and clinical parsimony. In order of shortest to longest time-to-first use, the 4 classes were characterized as 1) high craving and withdrawal, 2) intermediate craving and withdrawal, 3) high initial craving with low craving and withdrawal trajectories and 4) a low initial craving with low craving and withdrawal trajectories. Odds ratio calculations showed statistically significant differences in time-to-first use across classes. CONCLUSIONS Generally, participants with lower baseline levels and greater decreases in craving and withdrawal during stabilization combined with slower craving and withdrawal rebound during buprenorphine taper remained opioid-free longer. This exploratory work expanded on the importance of monitoring craving and withdrawal during buprenorphine induction, stabilization, and taper. Future research may allow individually tailored and timely interventions to be developed to extend time-to-first opioid use.
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Affiliation(s)
- Thomas F Northrup
- Department of Family and Community Medicine, University of Texas Medical School at Houston, 6431 Fannin Street, JJL 324, Houston, TX 77030, USA.
| | - Angela L Stotts
- Department of Family and Community Medicine, University of Texas Medical School at Houston, 6431 Fannin Street, JJL 324, Houston, TX 77030, USA; Department of Psychiatry and Behavioral Sciences, University of Texas Medical School at Houston, 1941 East Road, Houston, TX 77054, USA
| | - Charles Green
- Department of Psychiatry and Behavioral Sciences, University of Texas Medical School at Houston, 1941 East Road, Houston, TX 77054, USA; Department of Pediatrics, University of Texas Medical School at Houston, 6431 Fannin Street, MSB 3.020, Houston, TX 77030, USA
| | - Jennifer S Potter
- University of Texas Health Science Center at San Antonio, Department of Psychiatry, Mail Code 7792, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900, USA; McLean Hospital, Division of Alcohol and Drug Abuse & Harvard Medical School, Department of Psychiatry, 115 Mill Street, Belmont, MA 02478, USA
| | - Elise N Marino
- University of Texas Health Science Center at San Antonio, Department of Psychiatry, Mail Code 7792, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900, USA
| | - Robrina Walker
- University of Texas Southwestern Medical Center, Department of Psychiatry, 5323 Harry Hines Blvd., Dallas, TX 75390-9119, USA
| | - Roger D Weiss
- McLean Hospital, Division of Alcohol and Drug Abuse & Harvard Medical School, Department of Psychiatry, 115 Mill Street, Belmont, MA 02478, USA
| | - Madhukar Trivedi
- University of Texas Southwestern Medical Center, Department of Psychiatry, 5323 Harry Hines Blvd., Dallas, TX 75390-9119, USA
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Wang PW, Lin HC, Wu HC, Hsu CY, Chung KS, Ko CH, Yen CF. Explicit and implicit heroin-related cognitions and heroin use among patients receiving methadone maintenance treatment. Compr Psychiatry 2015; 56:155-60. [PMID: 25263518 DOI: 10.1016/j.comppsych.2014.08.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 08/09/2014] [Accepted: 08/14/2014] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Craving is an important issue in substance use disorder. To achieve a better understanding of the cognitive processing systems of craving, the cognitive processes of craving have been considered as two distinct processes. One system, based on rule-based inferences and named explicit cognition, is more conscious and effortful. The other system, based on prior learned association and named implicit cognition, is unconscious and effortless. How explicit and implicit cognitions are associated with heroin use in patients with methadone maintenance treatment (MMT) is not clear. This study aimed to explore the relationship between explicit and implicit cognition and heroin use in patients undergoing MMT. METHOD This study recruited one-hundred forty intravenous heroin users. The participants were invited to provide social-demographic data, the severity of substance dependence and explicit cognition with regard to heroin. Then, participants completed a computerized test to assess implicit cognition with regards to heroin. RESULTS This study found that explicit and implicit heroin-related cognitions were associated with the frequency of heroin use. There was an interaction effect between implicit and explicit cognition on the frequency of heroin use. This study also found that higher explicit heroin-related cognition was a risk factor for continuing heroin use. CONCLUSION Both explicit and implicit cognitions were associated with the frequency of heroin use in patients undergoing MMT, but only explicit cognition was associated with whether patients could stop using heroin during MMT. Therefore, the status of heroin use in patients undergoing MMT may be related to different cognitive processes.
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Affiliation(s)
- Peng-Wei Wang
- Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Psychiatry, Faculty of Medicine and Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Huang-Chi Lin
- Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Psychiatry, Faculty of Medicine and Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hung-Chi Wu
- Departments of Addiction Science, Kai-Suan Psychiatric Hospital, Kaohsiung, Taiwan
| | - Chih-Yao Hsu
- Departments of Addiction Science, Kai-Suan Psychiatric Hospital, Kaohsiung, Taiwan
| | - Kuan-Sheng Chung
- Departments of Addiction Science, Kai-Suan Psychiatric Hospital, Kaohsiung, Taiwan
| | - Chih-Hung Ko
- Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Psychiatry, Faculty of Medicine and Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Psychiatry, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Fang Yen
- Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Psychiatry, Faculty of Medicine and Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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Schwartz RP, Kelly SM, Gryczynski J, Mitchell SG, O’Grady KE, Jaffe JH. Heroin Use, HIV-Risk, and Criminal Behavior in Baltimore: Findings from Clinical Research. J Addict Dis 2015; 34:151-61. [PMID: 26079104 PMCID: PMC4550504 DOI: 10.1080/10550887.2015.1059222] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This article reviews research conducted in Baltimore over the past 15 years, examining the following: (1) What factors differentiate heroin-addicted individuals who enter methadone treatment from those who do not? (2) How difficult is gaining access to methadone treatment? (3) What are effective ways to overcome barriers to treatment entry? (4) Why do so many methadone patients drop out of treatment prematurely? (5) What are the added benefits of counseling when coupled with methadone or buprenorphine treatment? (6) Does increasing access to treatment have an impact on overdose deaths? Specific recommendations are made for policymakers concerned with addressing heroin addiction.
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Affiliation(s)
| | | | | | | | | | - Jerome H. Jaffe
- Friends Research Institute, Inc, Baltimore, MD, USA
- University of Maryland School of Medicine, Department of Psychiatry, Baltimore, MD USA
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Klimas J, Tobin H, Field CA, O'Gorman CSM, Glynn LG, Keenan E, Saunders J, Bury G, Dunne C, Cullen W. Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users. Cochrane Database Syst Rev 2014:CD009269. [PMID: 25470303 DOI: 10.1002/14651858.cd009269.pub3] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Problem alcohol use is common among illicit drug users and is associated with adverse health outcomes. It is also an important factor contributing to a poor prognosis among drug users with hepatitis C virus (HCV) as it impacts on progression to hepatic cirrhosis or opiate overdose in opioid users. OBJECTIVES To assess the effects of psychosocial interventions for problem alcohol use in illicit drug users (principally problem drug users of opiates and stimulants). SEARCH METHODS We searched the Cochrane Drugs and Alcohol Group trials register (June 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 11, June 2014), MEDLINE (1966 to June 2014); EMBASE (1974 to June 2014); CINAHL (1982 to June 2014); PsycINFO (1872 to June 2014) and the reference lists of eligible articles. We also searched: 1) conference proceedings (online archives only) of the Society for the Study of Addiction, International Harm Reduction Association, International Conference on Alcohol Harm Reduction and American Association for the Treatment of Opioid Dependence; 2) online registers of clinical trials: Current Controlled Trials, Clinical Trials.org, Center Watch and the World Health Organization International Clinical Trials Registry Platform. SELECTION CRITERIA Randomised controlled trials comparing psychosocial interventions with another therapy (other psychosocial treatment, including non-pharmacological therapies, or placebo) in adult (over the age of 18 years) illicit drug users with concurrent problem alcohol use. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS Four studies, involving 594 participants, were included. Half of the trials were rated as having a high or unclear risk of bias. The studies considered six different psychosocial interventions grouped into four comparisons: (1) cognitive-behavioural coping skills training versus 12-step facilitation (one study; 41 participants), (2) brief intervention versus treatment as usual (one study; 110 participants), (3) group or individual motivational interviewing (MI) versus hepatitis health promotion (one study; 256 participants) and (4) brief motivational intervention (BMI) versus assessment-only (one study; 187 participants). Differences between studies precluded any data pooling. Findings are described for each trial individually.Comparison 1: low-quality evidence; no significant difference for any of the outcomes considered Alcohol abstinence as maximum number of weeks of consecutive alcohol abstinence during treatment: mean difference (MD) 0.40 (95% confidence interval (CI) -1.14 to 1.94); illicit drug abstinence as maximum number of weeks of consecutive abstinence from cocaine during treatment: MD 0.80 (95% CI -0.70 to 2.30); alcohol abstinence as number achieving three or more weeks of consecutive alcohol abstinence during treatment: risk ratio (RR) 1.96 (95% CI 0.43 to 8.94); illicit drug abstinence as number achieving three or more weeks of consecutive abstinence from cocaine during treatment: RR 1.10 (95% CI 0.42 to 2.88); alcohol abstinence during follow-up year: RR 2.38 (95% CI 0.10 to 55.06); illicit drug abstinence as abstinence from cocaine during follow-up year: RR 0.39 (95% CI 0.04 to 3.98), moderate-quality evidence.Comparison 2: low-quality evidence, no significant difference for all the outcomes considered Alcohol use as AUDIT scores at three months: MD 0.80 (95% -1.80 to 3.40); alcohol use as AUDIT scores at nine months: MD 2.30 (95% CI -0.58 to 5.18); alcohol use as number of drinks per week at three months: MD 0.70 (95% CI -3.85 to 5.25); alcohol use as number of drinks per week at nine months: MD -0.30 (95% CI -4.79 to 4.19); alcohol use as decreased alcohol use at three months: RR 1.13 (95% CI 0.67 to 1.93); alcohol use as decreased alcohol use at nine months: RR 1.34 (95% CI 0.69 to 2.58), moderate-quality evidence.Comparison 3 (group and individual MI), low-quality evidence: no significant difference for all outcomes Group MI: number of standard drinks consumed per day over the past month: MD -0.40 (95% CI -2.03 to 1.23); frequency of drug use: MD 0.00 (95% CI -0.03 to 0.03); composite drug score (frequency*severity for all drugs taken): MD 0.00 (95% CI -0.42 to 0.42); greater than 50% reduction in number of standard drinks consumed per day over the last 30 days: RR 1.10 (95% CI 0.82 to 1.48); abstinence from alcohol over the last 30 days: RR 0.88 (95% CI 0.49 to 1.58).Individual MI: number of standard drinks consumed per day over the past month: MD -0.10 (95% CI -1.89 to 1.69); frequency of drug use (as measured using the Addiction Severity Index (ASI drug): MD 0.00 (95% CI -0.03 to 0.03); composite drug score (frequency*severity for all drugs taken): MD -0.10 (95% CI -0.46 to 0.26); greater than 50% reduction in number of standard drinks consumed per day over the last 30 days: RR 0.92 (95% CI 0.68 to 1.26); abstinence from alcohol over the last 30 days: RR 0.97 (95% CI 0.56 to 1.67).Comparison 4: more people reduced alcohol use (by seven or more days in the past month at 6 months) in the BMI group than in the control group (RR 1.67; 95% CI 1.08 to 2.60), moderate-quality evidence. No significant difference was reported for all other outcomes: number of days in the past 30 days with alcohol use at one month: MD -0.30 (95% CI -3.38 to 2.78); number of days in the past month with alcohol use at six months: MD -1.50 (95% CI -4.56 to 1.56); 25% reduction of drinking days in the past month: RR 1.23 (95% CI 0.96 to 1.57); 50% reduction of drinking days in the past month: RR 1.27 (95% CI 0.96 to 1.68); 75% reduction of drinking days in the past month: RR 1.21 (95% CI 0.84 to 1.75); one or more drinking days' reduction in the past month: RR 1.12 (95% CI 0.91 to 1.38). AUTHORS' CONCLUSIONS There is low-quality evidence to suggest that there is no difference in effectiveness between different types of interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users and that brief interventions are not superior to assessment-only or to treatment as usual. No firm conclusions can be made because of the paucity of the data and the low quality of the retrieved studies.
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Affiliation(s)
- Jan Klimas
- Addiction & Urban Health Research Initiative, BC Centre for Excellence in HIV/AIDS, 611 Powell Street, Vancouver, BC, V6A 1H2, Canada.
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Fairbairn N, Hayashi K, Ti L, Kaplan K, Suwannawong P, Wood E, Kerr T. Compulsory drug detention and injection drug use cessation and relapse in Bangkok, Thailand. Drug Alcohol Rev 2014; 34:74-81. [PMID: 25302711 DOI: 10.1111/dar.12206] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 08/14/2014] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND AIMS Strategies to promote the reduction and cessation of injection drug use are central to human immunodeficiency virus prevention and treatment efforts globally. Though drug use cessation is a major focus of drug policy in Thailand, little is known about factors associated with injection cessation and relapse in this setting. DESIGN AND METHODS A cross-sectional study was conducted between July and October 2011 of a community-recruited sample of people who inject drugs in Bangkok, Thailand. Using multivariate logistic regression, we examined the prevalence and correlates of injection drug use cessation with subsequent relapse. RESULTS Among 422 participants, 209 (49.5%) reported a period of injection drug use cessation of at least one year. In multivariate analyses, incarceration (adjusted odds ratio [AOR] 13.07), voluntary drug treatment (AOR 2.75), midazolam injection (AOR 2.48) and number of years since first injection (AOR 1.07) were positively associated with injection cessation of duration greater than a year (all P < 0.05). Exposure to compulsory drug detention was positively associated (AOR 2.61) and methadone treatment was negatively associated (AOR 0.38) with short-term cessation only. Injection drug use cessation was most often due to incarceration (74%), and relapse was associated with release from prison (66%). DISCUSSION AND CONCLUSION Half of the study participants had previously stopped injecting drugs for more than a year, and this was strongly associated with incarceration. Compulsory drug detention was associated with short-term cessation and relapse. A range of evidence-based strategies should be made available to facilitate sustained cessation of injection drug use in Thailand.
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Affiliation(s)
- Nadia Fairbairn
- Urban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, Canada
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Dale-Perera A, Alam F, Barker P. Opioid-dependence treatment in the era of recovery: insights from a UK survey of physicians, patients and out-of-treatment opioid users. JOURNAL OF SUBSTANCE USE 2014. [DOI: 10.3109/14659891.2014.923532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Schwartz RP, Alexandre PK, Kelly SM, O'Grady KE, Gryczynski J, Jaffe JH. Interim versus standard methadone treatment: a benefit-cost analysis. J Subst Abuse Treat 2013; 46:306-14. [PMID: 24239030 DOI: 10.1016/j.jsat.2013.10.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 09/23/2013] [Accepted: 10/04/2013] [Indexed: 10/26/2022]
Abstract
A benefit-cost analysis was conducted as part of a clinical trial in which newly-admitted methadone patients were randomly assigned to interim methadone (IM; methadone without counseling) for the first 4 months of 12 months of methadone treatment or 12 months of methadone with one of two counseling conditions. Health, residential drug treatment, criminal justice costs, and income data in 2010 dollars were obtained at treatment entry, and 4- and 12-month follow-up from 200 participants and program costs were obtained. The net benefits of treatment were greater for the IM condition but controlling for the baseline variables noted above, the difference between conditions in net monetary benefits was not significant. For the combined sample, there was a pre- to post-treatment net benefit of $1470 (95% CI: -$625; $3584) and a benefit-cost ratio of 1.5 (95% CI: 0.8, 2.3), but using our conservative approach to calculating benefits, these values were not significant.
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Affiliation(s)
| | - Pierre K Alexandre
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | | | - Kevin E O'Grady
- Department of Psychology, University of Maryland, College Park, MD 20742, USA
| | | | - Jerome H Jaffe
- Friends Research Institute, Baltimore, MD 21201, USA; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; University of Maryland School of Medicine, Department of Psychiatry, Baltimore, MD 21201, USA
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Fu JJ, Zaller ND, Yokell MA, Bazazi AR, Rich JD. Forced withdrawal from methadone maintenance therapy in criminal justice settings: a critical treatment barrier in the United States. J Subst Abuse Treat 2013; 44:502-5. [PMID: 23433809 PMCID: PMC3695471 DOI: 10.1016/j.jsat.2012.10.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 09/28/2012] [Accepted: 10/22/2012] [Indexed: 01/14/2023]
Abstract
The World Health Organization classifies methadone as an essential medicine, yet methadone maintenance therapy remains widely unavailable in criminal justice settings throughout the United States. Methadone maintenance therapy is often terminated at the time of incarceration, with inmates forced to withdraw from this evidence-based therapy. We assessed whether these forced withdrawal policies deter opioid-dependent individuals in the community from engaging methadone maintenance therapy in two states that routinely force inmates to withdraw from methadone (N = 205). Nearly half of all participants reported that concern regarding forced methadone withdrawal during incarceration deterred them engaging methadone maintenance therapy in the community. Participants in the state where more severe methadone withdrawal procedures are used during incarceration were more likely to report concern regarding forced withdrawal as a treatment deterrent. Methadone withdrawal policies in the criminal justice system may be a broader treatment deterrent for opioid-dependent individuals than previously realized. Redressing this treatment barrier is both a health and human rights imperative.
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Affiliation(s)
- Jeannia J Fu
- Yale University School of Medicine, Section of Infectious Diseases, New Haven, CT 06510, USA.
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