Feasibility and outcome of substitution treatment of heroin-dependent patients in specialized substitution centers and primary care facilities in Germany: a naturalistic study in 2694 patients

SARS-CoV-2-Infection in People Addicted to Illegal Drugs - Is There a Protective Effect of Opioid Maintenance Treatment?

INTRODUCTION

People addicted to illegal drugs were discussed as a risk group for SARS-CoV-2 infections, with increased susceptibility and a severe course of infection.

METHODS

In this study, the frequency of SARS-CoV-2 infections of drug-dependent persons admitted to inpatient detoxification treatment in five psychiatric hospitals was determined by implementing routine polymerase chain reaction (PCR)-testing at admission (9/2020) up to one year. Main substance-related diagnosis, comorbid respiratory disease, housing situation, and current opioid maintenance treatment (OMT) were documented. An age-matched control group of psychiatric inpatients without dependence from illegal drugs was established.

RESULTS

Data from 1675 patients (male 79.5%; mean age 39.5 years; opioid dependence 81.5% homelessness; 2.4%; chronic respiratory disease 6.3%) were included. Out of 1365 patients dependent on opioids, 50.2% were currently in OMT. Six (3 female; mean age 40.3 years) patients tested positive for SARS-CoV-2 by PCR (0.36%), and none showed symptoms of COVID-19. All six were opioid dependent, 5 currently not in OMT. In the control group, 11 out of 1811 inpatients tested positive (0.61%).

DISCUSSION

The rate of SARS-CoV-2-infections in persons with dependence on illegal drugs was not increased compared to a control group of psychiatric patients. OMT is presumably a protective factor, e. g. in the participating cities, OMT facilities offered an easy access to vaccination programs. In contrast, drug addicts in the USA were severely affected by the pandemic. Differences between countries might partially be explained by social factors such as the higher availability of OMT in Germany and a much lower frequency of homelessness.

[Challenges in the treatment of opioid dependence]

BACKGROUND

The number of persons using opioids has increased worldwide in the last decade, particularly the use of opioid analgesics in North America and Africa. In Germany, the prevalence of heroin addiction has remained relatively stable.

METHOD

Narrative review of the literature.

RESULTS

Opioid-assisted maintenance treatment (OMT) with the established substances methadone, levomethadone, slow-release morphine and buprenorphine is recommended as the first-line treatment for heroin dependence. The OMT reduces the use of heroin, mortality and individual suffering and improves the quality of life and physical health. A diamorphine and heroine-assisted treatment is an option for people who do not benefit from conventional OMT. An alternative to the use of diamorphine could be treatment with hydromorphone hydrochloride. The regulations on carrying out maintenance treatment in the Controlled Substances Prescription Act and the guidelines of the Federal Medical Association in Germany have been loosened based on the experiences of the COVID-19 pandemic, for example with respect to take-home prescriptions. There is an ongoing intensive discussion on how to deal with the decreasing number of outpatient clinics offering OMT.

CONCLUSION

The first-line treatment for opioid addiction is opioid-assisted substitution treatment, including diamorphine and heroin-assisted treatment. Long-acting depot medications and implants still play a subordinate role.

Sociodemographic and Clinical Characteristics Associated with Improvements in Quality of Life for Participants with Opioid Use Disorder

Background: The Houston Emergency Opioid Engagement System was established to create an access pathway into long-term recovery for individuals with opioid use disorder. The program determines effectiveness across multiple dimensions, one of which is by measuring the participant’s reported quality of life (QoL) at the beginning of the program and at successive intervals. Methods: A visual analog scale was used to measure the change in QoL among participants after joining the program. We then identified sociodemographic and clinical characteristics associated with changes in QoL. Results: 71% of the participants (n = 494) experienced an increase in their QoL scores, with an average improvement of 15.8 ± 29 points out of a hundred. We identified 10 factors associated with a significant change in QoL. Participants who relapsed during treatment experienced minor increases in QoL, and participants who attended professional counseling experienced the largest increases in QoL compared with those who did not. Conclusions: Insight into significant factors associated with increases in QoL may inform programs on areas of focus. The inclusion of counseling and other services that address factors such as psychological distress were found to increase participants’ QoL and success in recovery.

Initiation of Low-threshold Buprenorphine in Nontreatment Seeking Patients With Opioid Use Disorder Engaged in Hepatitis C Treatment

OBJECTIVE

The ANCHOR program offered buprenorphine treatment to people who inject drugs engaged in hepatitis C (HCV) treatment at a Washington, DC harm reduction organization. This analysis describes the program model and outcomes of the opioid care continuum at 1 year.

METHODS

Primary outcomes were initiation of buprenorphine and retention in care, defined by an active buprenorphine prescription at given time points. Secondary outcomes included treatment interruptions, reasons for treatment noninitiation and termination, buprenorphine and opiate use, and HIV risk behaviors. Buprenorphine and opiate use were measured by urine toxicology screens and HIV risk behavior was quantified using a validated survey.

RESULTS

Of 67 patients receiving HCV treatment not on opioid agonist therapy at baseline, 96% (n = 64) were interested and 73% (n = 49) initiated buprenorphine. Retention was 82% (n = 40), 65% (n = 32), and 59% (n = 29) at months 1, 6, and 12, respectively. Retention at 12 months was associated with self-reported engagement in routine medical care (P < 0.01), but was not associated with gender, stable housing, past opioid agonist therapy, or past overdose. Among retained patients, urine screens positive for opioids were 73% (n = 29), 56% (n = 18), and 79% (n = 23) at months 1, 6, and 12. There was a significant mean decrease in HIV risk-taking behavior scores over the treatment period, primarily driven by reduced injection frequency.

CONCLUSIONS

Patients engaged in HCV treatment at a harm reduction organization showed a high rate of initiation of buprenorphine treatment, with retention comparable to other treatment settings. Although most patients continued using opioids on treatment, there was a reduced frequency of injection drug use, a significant driver of OUD-related risk. These data support the use of low-threshold buprenorphine access alongside HCV treatment to reduce morbidity and mortality in people with OUD.

Prospective Study on Factors Associated with Referral of Patients with Opioid Maintenance Therapy from Specialized Addictive Disorders Centers to Primary Care

Background: One of the most important issues for opiate maintenance therapy efficacy is the involvement of primary care physicians (PCPs) in opiate use disorder treatment, especially after referral from specialized units. This study aimed to analyze the progress of subjects in a specialized center and after referral to PCPs. Methods: This study was an observational prospective study. Recruitment took place in a specialized addictive disorder center in western France. All patients were evaluated (sociodemographical data, severity of substance use disorders through the TMSP scale, the quality of life through the TEAQV scale) by physicians during the 5-year-follow up of the study. Analysis focused on four main times during follow-up: entry/last visit into specialized care and into primary care. Results: 113 patients were included in this study; 93% were receiving methadone and 7% buprenorphine. Ninety (90) were referred to primary care. In primary care follow-up, the probability of the lowest severity score for substance use disorders remained stable over time. Conclusions: In daily practice, a center specialized in addictive disorders referred OMT management to PCPs for a majority of patients, and benefits regarding substance use disorders severity and quality of life remained stable after referral. Our results need to be confirmed.

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

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

Substances detected in used syringes of injecting drug users across 7 cities in Europe in 2017 and 2018: The European Syringe Collection and Analysis Project Enterprise (ESCAPE)

BACKGROUND AND AIMS

Injecting drug use is a matter of public health concern, associated with risks of overdoses, addiction and increased risk of bloodborne viral transmissions. Self-reported data on substances injected can be inaccurate or subject to bias or drug users might be oblivious to their injected substances or adulterations. Gathering of robust analytical information on the actual composition of substances injected might provide better information about the drugs that are being used. Therefore, this study aimed to analyse the residual content of discarded syringes collected across 7 European cities, collectively called the European Syringe Collection and Analysis Project Enterprise (ESCAPE).

METHODS

Used syringes were collected at street automatic injection kit dispensers or at harm-reduction services in Amsterdam, Budapest, Cologne, Glasgow, Helsinki, Lausanne and Paris. Two sampling periods were executed thus far, in 2017 and 2018. Qualitative chemical analysis of the content of used syringes was performed combining gas chromatographic (GC) and ultra(high)performance liquid chromatographic ((U)HPLC) analytical techniques with detection by mass spectrometry (MS).

RESULTS

Substances detected most frequently across both campaigns were cocaine, heroin, buprenorphine, amphetamines and synthetic cathinones. In Amsterdam, Cologne, Lausanne and Glasgow heroin and cocaine were the psychoactive substances most often detected, often in conjunction with each other. Helsinki showed a high presence of buprenorphine and amphetamines. In Budapest and Paris, synthetic cathinones were frequently detected. Less synthetic cathinones and cocaine was detected in 2018, whereas buprenorphine was detected almost twice as much. Inner-city variations were found, probably reflecting the types of people who inject drugs (PWID) in different areas of the city.

CONCLUSION

Overall, laboratory-confirmed local data on injected substances showed resemblance to national surveys done among PWID. However, the ESCAPE data also showed some interesting differences, showing it can be used for local interventions and complementing existing monitoring data.

Buprenorphine-cannabis interaction in patients undergoing opioid maintenance therapy

Buprenorphine is a partial μ-opioid agonist widely used for opioid maintenance therapy (OMT). It is mainly metabolized to pharmacologically active norbuprenorphine by the cytochrome P450 (CYP) isozyme 3A4. This may give rise to drug-drug interactions under combinations with inhibitors or inducers of CYP3A4. Cannabis is a potential inhibitor of CYP3A4, and there is a large degree of concomitant cannabis use among OMT patients. We performed a retrospective analysis on liver healthy OMT patients substituted with buprenorphine, either with (n = 15) or without (n = 17) concomitant use of cannabis. Patients with additional illicit drugs or medications affecting CYP3A were excluded. Measured blood concentrations of buprenorphine and norbuprenorphine were compared between the two groups. Cannabis users and non-users received similar doses, but users had 2.7-fold higher concentrations of buprenorphine (p < 0.01) and 1.4-fold for norbuprenorphine (1.4-fold, p = 0.07). Moreover, the metabolite-to-parent drug ratio was 0.98 in non-users and 0.38 in users (p = 0.02). Female gender did not produce significant effects. These findings indicate that cannabis use decreases the formation of norbuprenorphine and elevates buprenorphine and norbuprenorphine concentrations in blood most probably by inhibition of CYP3A4. The pharmacokinetic interaction may give rise to enhanced or altered opioid activity and risk of intoxications. Physicians should inform patients about this risk and supervise cannabis users by regular control of buprenorphine blood levels, i.e., by therapeutic drug monitoring.

Decision making of individuals with heroin addiction receiving opioid maintenance treatment compared to early abstinent users

BACKGROUND AND AIMS

Individuals with heroin addiction are prone to dysfunctional decision-making. They frequently choose the short-term rewarding option of drug intake despite experiencing long-term negative consequences. Opioid maintenance treatment (OMT) is the most common treatment of heroin addiction.

METHODS

In this study, 38 individuals in an early stage of abstinence from heroin addiction (ESA-HA individuals) at the end of inpatient detoxification treatment and 41 individuals in long-term OMT were examined. Decision-making was assessed by (I) a modified version of the Iowa Gambling Task (IGT) with drug-related stimuli focusing on decision-making under ambiguity and (II) the Game of Dice Task (GDT) assessing decision-making under objective risk.

RESULTS

OMT-individuals showed significantly better performance in the IGT than the ESA-HA-individuals. They also showed significantly less craving under exposure of drug-related pictures. In the GDT, OMT-individuals showed significantly less risky decision-making than ESA-HA-individuals.

CONCLUSION

The results suggest that patients receiving OMT show better functional decision-making and lower craving reactions. It could be assumed that the effectiveness of OMT in preventing relapse is linked to better decision-making and lower craving among these patients.

Effects of medication-assisted treatment on mortality among opioids users: a systematic review and meta-analysis

Opioid use disorder (OUD) is associated with a high risk of premature death. Medication-assisted treatment (MAT) is the primary treatment for opioid dependence. We comprehensively assessed the effects of different MAT-related characteristics on mortality among those with OUD by a systematic review and meta-analysis. The all-cause and overdose crude mortality rates (CMRs) and relative risks (RRs) by treatment status, different type, period, and dose of medication, and retention time were pooled using random effects, subgroup analysis, and meta-regression. Thirty cohort studies involving 370,611 participants (1,378,815 person-years) were eligible in the meta-analysis. From 21 studies, the pooled all-cause CMRs were 0.92 per 100 person-years (95% CI: 0.79-1.04) while receiving MAT, 1.69 (1.47-1.91) after cessation, and 4.89 (3.54-6.23) for untreated period. Based on 16 studies, the pooled overdose CMRs were 0.24 (0.20-0.28) while receiving MAT, 0.68 (0.55-0.80) after cessation of MAT, and 2.43 (1.72-3.15) for untreated period. Compared with patients receiving MAT, untreated participants had higher risk of all-cause mortality (RR 2.56 [95% CI: 1.72-3.80]) and overdose mortality (8.10 [4.48-14.66]), and discharged participants had higher risk of all-cause death (2.33 [2.02-2.67]) and overdose death (3.09 [2.37-4.01]). The all-cause CMRs during and after opioid substitution treatment with methadone or buprenorphine were 0.93 (0.76-1.10) and 1.79 (1.47-2.10), and corresponding estimate for antagonist naltrexone treatment were 0.26 (0-0.59) and 1.97 (0-5.18), respectively. Retention in MAT of over 1-year was associated with a lower mortality rate than that with retention ≤1 year (1.62, 1.31-1.93 vs. 5.31, -0.09-10.71). Improved coverage and adherence to MAT and post-treatment follow-up are crucial to reduce the mortality. Long-acting naltrexone showed positive advantage on prevention of premature death among persons with OUD.

Effectiveness of a Psycho-Social Intervention Aimed at Reducing Attrition at Methadone Maintenance Treatment Clinics: A Propensity Score Matching Analysis

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.

Buprenorphine and Methadone as Opioid Maintenance Treatments for Heroin-Addicted Patients Induce Oxidative Stress in Blood

Buprenorphine and methadone are two substances widely used in the substitution treatment of patients who are addicted to opioids. Although it is known that they partly act efficiently towards this direction, there is no evidence regarding their effects on the redox status of patients, a mechanism that could potentially improve their action. Therefore, the aim of the present investigation was to examine the impact of buprenorphine and methadone, which are administered as substitutes to heroin-dependent patients on specific redox biomarkers in the blood. From the results obtained, both the buprenorphine (n = 21) and the methadone (n = 21) groups exhibited oxidative stress and compromised antioxidant defence. This was evident by the decreased glutathione (GSH) concentration and catalase activity in erythrocytes and the increased concentrations of thiobarbituric acid reactive substances (TBARS) and protein carbonyls in the plasma, while there was no significant alteration of plasma total antioxidant capacity (TAC) compared to the healthy individuals (n = 29). Furthermore, methadone revealed more severe oxidant action compared to buprenorphine. Based on relevant studies, the tested substitutes mitigate the detrimental effects of heroin on patient redox status; still it appears that they need to be boosted. Therefore, concomitant antioxidant administration could potentially enhance their beneficial action, and most probably, buprenorphine that did not induce oxidative stress in such a severe mode as methadone, on the regulation of blood redox status.

Can Tramadol be Used for Maintenance Treatment of Opioid Dependence?

BACKGROUND

Certain limitations of the existing opioid substitution therapies necessitate exploration of other options for maintenance of patients with opioid dependence. This study aimed to present the experience of use of tramadol for long-term treatment of patients with opioid dependence.

METHODS

This was a cross-sectional interview-based observational study conducted in Uttar Pradesh state in India. Patients with opioid dependence who received oral tramadol treatment for a period of more than 6 months were recruited. Outcome was assessed in terms of self-reported abstinence on tramadol.

RESULTS

A total of 102 participants were recruited in the study, with a mean age of 41.3 years. All the participants were males. Abstinence to extraneous opioids was reported by 58.8% of the sample, and the median dose of tramadol at which abstinence was achieved was 350 mg/d. Those who reported to be taking natural opioids (raw opium or poppy husk) at the time of seeking treatment had higher rates of achieving abstinence.

CONCLUSIONS

Tramadol may be a possible option for the maintenance treatment among some opioid-dependent individuals. Further studies are required to establish its efficacy vis-à-vis other medications used in opioid substitution treatment.

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

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

The impact of buprenorphine and methadone on mortality: a primary care cohort study in the United Kingdom

AIMS

To estimate whether opioid substitution treatment (OST) with buprenorphine or methadone is associated with a greater reduction in the risk of all-cause mortality (ACM) and opioid drug-related poisoning (DRP) mortality.

DESIGN

Cohort study with linkage between clinical records from Clinical Practice Research Datalink and mortality register.

SETTING

UK primary care.

PARTICIPANTS

A total of 11 033 opioid-dependent patients who received OST from 1998 to 2014, followed-up for 30 410 person-years.

MEASUREMENTS

Exposure to methadone (17 373, 61%) OST episodes or buprenorphine (9173, 39%) OST episodes. ACM was available for all patients; information on cause of death and DRP was available for 5935 patients (54%) followed-up for 16 363 person-years. Poisson regression modelled mortality by treatment period with an interaction between OST type and treatment period (first 4 weeks on OST, rest of time off OST, first 4 weeks off OST, rest of time out of OST censored at 12 months) to test whether ACM or DRP differed between methadone and buprenorphine. Inverse probability weights were included to adjust for confounding and balance characteristics of patients prescribed methadone or buprenorphine.

FINDINGS

ACM and DRP rates were 1.93 and 0.53 per 100 person-years, respectively. DRP was elevated during the first 4 weeks of OST [incidence rate ratio (IRR) = 1.93 95% confidence interval (CI) = 0.97-3.82], the first 4 weeks off OST (IRR = 8.15, 95% CI = 5.45-12.19) and the rest of time out of OST (IRR = 2.13, 95% CI = 1.47-3.09) compared with mortality risk from 4 weeks to end of treatment. Patients on buprenorphine compared with methadone had lower ACM rates in each treatment period. After adjustment, there was evidence of a lower DRP risk for patients on buprenorphine compared with methadone at treatment initiation (IRR = 0.08, 95% CI = 0.01-0.48) and rest of time on treatment (IRR = 0.37, 95% CI = 0.17-0.79). Treatment duration (mean and median) was shorter on buprenorphine than methadone (173 and 40 versus 363 and 111, respectively). Model estimates suggest that there was a low probability that methadone or buprenorphine reduced the number of DRP in the population: 28 and 21%, respectively.

CONCLUSIONS

In UK general medical practice, opioid substitution treatment with buprenorphine is associated with a lower risk of all-cause and drug-related poisoning mortality than methadone. In the population, buprenorphine is unlikely to give greater overall protection because of the relatively shorter duration of treatment.

Concomitant drug abuse of opioid dependent patients in maintenance treatment detected with a multi-target screening of oral fluid

BACKGROUND AND OBJECTIVES

Numbers of drug-related deaths have been growing in Europe and the USA, especially those attributable to mixed drug consumption. Overdose deaths account for about one third up to one half of all illicit drug deaths worldwide. In most cases opioids are involved. Opioid maintenance treatment (OMT) is a well-established therapy option among people with opioid dependence. The aim of this study was to assess concomitant substance abuse in opioid-dependent patients under OMT in two centers in Munich, Germany.

METHODS

Oral fluid samples of opioid-dependent patients (n = 388) in OMT were randomly collected and analyzed by a multi-drug screening covering a wide range of psychotropic agents with UPLC-MS/MS techniques.

RESULTS

Fifty-one percent of the patients had concomitant substance abuse of at least one non-prescribed substance, 32% were positive for substances that were not tested in routine urine diagnostics, especially pregabalin. Fifty-seven percent received take-home opioid medication, and 26% had contact with underage children. Among the take-home subgroup, a concomitant substance abuse of 43.5% was detected. Furthermore 52.5% of the patients with contact to underaged children exhibited concomitant substance abuse.

CONCLUSIONS

Concomitant substance abuse is a serious issue among OMT patients. Screening for a broader range of substances than usually analyzed, reveals additional relevant abuse among OMT patients, including pregabalin-an anticonvulsant.

SCIENTIFIC SIGNIFICANCE

Our study underscores the importance of monitoring a broad range of substances including others than usually screened in opioid-dependent patients in OMT. (Am J Addict 2018;XX:1-6).

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

ISSUES

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

APPROACH

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

KEY FINDINGS

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

IMPLICATIONS AND CONCLUSION

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

Quality of life as an outcome of opioid use disorder treatment: A systematic review

BACKGROUND AND AIMS

The recent opioid epidemic has prompted renewed interest in opioid use disorder treatment, but there is little evidence regarding health-related quality-of-life (HRQoL) outcomes in treatment programs. Measuring HRQoL represents an opportunity to consider outcomes of opioid use disorder treatment that are more patient-centered and more relevant to overall health than abstinence alone. We conducted a systematic literature review to explore the extent to which the collection of HRQoL by opioid treatment programs is documented in the treatment program literature.

MATERIALS AND METHODS

We searched PubMed, Embase PsycINFO and Web of Science for papers published between 1965 and 2015 that reported HRQoL outcome measures from substance abuse treatment programs.

RESULTS

Of the 3014 unduplicated articles initially identified for screening, 99 articles met criteria for further review. Of those articles, 7 were unavailable in English; therefore 92 articles were reviewed. Of these articles, 44 included any quality-of-life measure, 17 of which included validated HRQoL measures, and 10 supported derivation of quality-adjusted life year utility weights. The most frequently used validated measure was the Addiction Severity Index (ASI). Non-U.S. and more recent studies were more likely to include a measure of HRQoL.

CONCLUSIONS

HRQoL measures are rarely used as outcomes in opioid treatment programs. The field should incorporate HRQoL measures as standard practice, especially measures that can be used to derive utility weights, such as the SF-12 or EQ-5D. These instruments provide policy makers with evidence on the impact of programs on patients' lives and with data to quantify the value of investing in opioid use disorder treatments.

Six-Year Outcome of Opioid Maintenance Treatment in Heroin-Dependent Patients: Results from a Naturalistic Study in a Nationally Representative Sample

BACKGROUND

In many countries, the opioid agonists, buprenorphine and methadone, are licensed for maintenance treatment of opioid dependence. Many short-term studies have been performed, but little is known about long-term effects. Therefore, this study described over 6 years (1) mortality, retention and abstinence rates and (2) changes in concomitant drug use and somatic and mental health.

METHODS

A prevalence sample of n = 2,694 maintenance patients, recruited from a nationally representative sample of n = 223 substitution doctors, was evaluated in a 6-year prospective-longitudinal naturalistic study. At 72 months, n = 1,624 patients were assessed for outcome; 1,147 had full outcome data, 346 primary outcome data and 131 had died; 660 individuals were lost to follow-up.

RESULTS

The 6-year retention rate was 76.6%; the average mortality rate was 1.1%. During follow-up, 9.4% of patients became "abstinent" and 1.9% were referred for drug-free addiction treatment. Concomitant drug use decreased and somatic health status and social parameters improved.

CONCLUSIONS

The study provides further evidence for the efficacy and safety of maintenance treatment with opioid agonists. In the long term, the number of opioid-free patients is low and most patients are more or less continuously under opioid maintenance therapy. Further implications are discussed.

The opiate dosage adequacy scale for identification of the right methadone dose--a prospective cohort study

BACKGROUND

Opioid maintenance treatment with methadone is regarded as gold standard in the therapy of opioid dependence. Identification of the 'right' methadone dose, however, remains challenging. We wanted to explore if the Opiate Dosage Adequacy Scale (ODAS) is a helpful instrument in methadone titration.

METHODS

Within this 12-months prospective naturalistic cohort study patients in stable maintenance treatment with methadone (Eptadone®) were included. Sociodemographic and clinical data were gathered at baseline, and months 3, 6, and 12. At the same points in time, the instruments ODAS, European Addiction Severity Index (EuropASI), and Derogatis Interview for Sexual Functioning-Self Report (DISF-SR) were applied.

RESULTS

Five hundred fifteen patients were enrolled, 129 patients prematurely terminated substitution treatment (treatment failure), in 108 patients substitution medication was changed, likely due to bitter taste of Eptadone®. Complete longitudinal ODAS and EuropASI data sets were available for 229 patients. The frequency of adequate methadone doses (ODAS) increased (60.9 % at baseline, 85.3 % at month 12) as well as the average daily methadone dose (63.8 (±30.8) mg/day at baseline to 69.6 (±36.0) mg/day at month 12). Inadequacy of methadone dose was not associated with treatment failure (RR 1.019; CI 95 % 0.756-1.374). Addiction severity decreased statistically significantly. Compared to adequately dosed patients, inadequately dosed patients benefited more, in that they showed greater improvements in ODAS scores, had higher increases in methadone dose, and partially experienced more advanced sexual functioning.

CONCLUSION

Application of ODAS was associated with improved methadone dose adequacy and addiction severity parameters as well as increased methadone doses. Its usefulness should be corroborated in a controlled trial.

Epidemiology of hepatitis C virus infection among people receiving opioid substitution therapy (ECHO): study protocol

BACKGROUND

Hepatitis C virus infection is highly prevalent among people who inject drugs. Opioid substitution therapy, the standard treatment for opioid dependence, provides an excellent opportunity for the treatment of hepatitis C virus infection due to the close and regular contact between patients and clinicians. However, there is little research on the impact of opioid substitution therapy on the prevalence of the hepatitis C virus at a national level. This paper describes the protocol for the Epidemiology of Hepatitis C Virus Infection among People Receiving Opioid Substitution Therapy (ECHO) study. The aim of this study is to estimate the national prevalence and incidence of hepatitis C virus infection among people receiving opioid substitution therapy in Germany and to describe factors associated with hepatitis C treatment uptake and seroconversion.

METHODS/DESIGN

An observational, longitudinal, multicentre study is being conducted between 2014 and 2016 in a representative sample of approximately 2500 people receiving opioid substitution therapy from about 100 clinicians providing opioid substitution therapy in Germany. Data will be collected during routine patient care and by means of patient and clinician questionnaires at baseline and 12-month follow-up. Stratified sampling will be performed to obtain a representative sample of clinicians providing opioid substitution therapy. The strata will be constructed based on the distribution of the total sample of clinicians providing opioid substitution therapy in Germany according to German Federal State and the number of patients per clinician.

DISCUSSION

Opioid substitution therapy may be an important strategy to prevent the spread of hepatitis C virus in opioid dependent populations, but its effectiveness may be diminished by our limited understanding of factors associated with treatment uptake and seroconversion. The present study will provide important information for developing strategies to address hepatitis C virus-related disease burden in people receiving opioid substitution therapy.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02395198.

The impact of low-threshold methadone maintenance treatment on mortality in a Canadian setting

BACKGROUND

Methadone maintenance therapy (MMT) is among the most effective treatment modalities available for the management of opioid use disorder. However, the effect of MMT on mortality, and optimal strategies for delivering methadone are less clear. This study sought to estimate the effect of low-threshold MMT and its association with all-cause mortality among persons who inject drugs (PWID) in a setting where methadone is widely available through primary care physicians and community pharmacies at no cost through the setting's universal medical insurance plan.

METHODS

Between May, 1996 and December, 2011 data were collected as part of two prospective cohort studies of PWID in Vancouver, Canada, and were linked to the provincial vital statistics database to ascertain rates and causes of death. The association of MMT with all-cause mortality was estimated using multivariable extended Cox regression with time-dependent variables.

RESULTS

Of 2335 PWID providing 15027 person-years of observation, 511 deaths were observed for a mortality rate of 3.4 (95% Confidence Interval [CI]: 3.1-3.7) deaths per 100 person-years. After adjusting for potential confounders including age and HIV seropositivity, MMT enrolment was found to be associated with lower mortality (adjusted hazard ratio [AHR]=0.73, 95% CI: 0.61-0.88).

CONCLUSIONS

While observed all-cause mortality rates among PWID in this setting were high, participation in low-threshold MMT was significantly associated with improved survival. These findings add to the known benefits of providing low-threshold MMT on reducing the harms associated with injection drug use.

Effect of low-threshold methadone maintenance therapy for people who inject drugs on HIV incidence in Vancouver, BC, Canada: an observational cohort study

BACKGROUND

HIV infection in people who inject drugs (PWID) is an international public health concern. We aimed to assess the effect of methadone maintenance therapy on HIV incidence in PWID in Vancouver, BC, Canada, where methadone is widely available through family physicians' offices and dispensed by community pharmacies.

METHODS

Data were derived from the Vancouver Injection Drug Users Study (VIDUS), a prospective cohort of PWID in Vancouver. Individuals were eligible to enrol in VIDUS if they had injected illicit drugs at least once in the previous month and lived in the Greater Vancouver region. Participants responded to an interviewer-administered questionnaire and provided blood samples at enrolment and follow-up visits every 6 months. We estimated time to HIV seroconversion with Kaplan-Meier methods and used Cox proportional hazards methods to assess associations between methadone use and time to seroconversion.

FINDINGS

1639 HIV-negative individuals were recruited between May 1, 1996, and May 31, 2013. Of these individuals, 138 had HIV seroconversion during a median of 75·5 months (IQR 33·4-115·3) of follow-up. In multivariate Cox regression analyses, methadone maintenance therapy remained independently associated with a reduced hazard of HIV infection after adjustment for sociodemographic characteristics and drug use patterns (adjusted relative hazard 0·64, 95% CI 0·41-0·98).

INTERPRETATION

Methadone maintenance therapy for PWID made available through primary care physicians and community pharmacies can help to achieve public health goals such as reducing the spread of HIV.

FUNDING

US National Institutes of Health, Canada Research Chair, Canadian Institutes of Health Research.

New developments in the management of opioid dependence: focus on sublingual buprenorphine-naloxone

Opioid maintenance therapy is a well-established first-line treatment approach in opioid dependence. Buprenorphine, a partial opioid agonist, has been found by numerous studies to be an effective and safe medication in the treatment of opioid dependence. At present, buprenorphine is available as a monodrug or in a fixed 4:1 ratio combination with naloxone. A diminished risk of diversion and abuse for the buprenorphine-naloxone combination is likely but not firmly established. Conventional formulations are given sublingually to avoid the hepatic first-pass effect. A novel film tablet is available only in the US and Australia. Other novel, sustained-release formulations (implant, depot) are currently being developed and tested. Recent studies, including a Cochrane meta-analysis, suggest that the retention with buprenorphine is lower than for methadone, but that buprenorphine may be associated with less drug use. Higher doses of buprenorphine are associated with better retention rates. Buprenorphine has a ceiling effect at the opioid receptor with regard to respiratory depression, and may cause fewer fatal intoxications than methadone. Possible antidepressant effects of buprenorphine and its use in comorbid psychiatric patients has not been studied in much detail. Clinical implications are discussed.

Methadone induction in primary care for opioid dependence: a pragmatic randomized trial (ANRS Methaville)

Objective

Methadone coverage is poor in many countries due in part to methadone induction being possible only in specialized care (SC). This multicenter pragmatic trial compared the effectiveness of methadone treatment between two induction models: primary care (PC) and SC.

Methods

In this study, registered at ClinicalTrials.Gov (NCT00657397), opioid-dependent individuals not on methadone treatment for at least one month or receiving buprenorphine but needing to switch were randomly assigned to start methadone in PC (N = 155) or in SC (N = 66) in 10 sites in France. Visits were scheduled at months M0, M3, M6 and M12. The primary outcome was self-reported abstinence from street-opioids at 12 months (M12) (with an underlying 15% non-inferiority hypothesis for PC). Secondary outcomes were abstinence during follow-up, engagement in treatment (i.e. completing the induction period), retention and satisfaction with the explanations provided by the physician. Primary analysis used intention to treat (ITT). Mixed models and the log-rank test were used to assess the arm effect (PC vs. SC) on the course of abstinence and retention, respectively.

Results

In the ITT analysis (n = 155 in PC, 66 in SC), which compared the proportions of street-opioid abstinent participants, 85/155 (55%) and 22/66 (33%) of the participants were classified as street-opioid abstinent at M12 in PC and SC, respectively. This ITT analysis showed the non-inferiority of PC (21.5 [7.7; 35.3]). Engagement in treatment and satisfaction with the explanations provided by the physician were significantly higher in PC than SC. Retention in methadone and abstinence during follow-up were comparable in both arms (p = 0.47, p = 0.39, respectively).

Conclusions

Under appropriate conditions, methadone induction in primary care is feasible and acceptable to both physicians and patients. It is as effective as induction in specialized care in reducing street-opioid use and ensuring engagement and retention in treatment for opioid dependence.

Trial registration

Number Eudract 2008-001338-28; ClinicalTrials.gov: NCT00657397; International Standard Randomized Controlled Trial Number Register ISRCTN31125511

Patients on Opioid Substitution Treatment in the Republic of Macedonia: What Do Treatment Demand Data Tell Us?

AIM: The aim of the survey is to analyze national data from opioid substitution treatment (OST) medical records and to compare it with the data from EU countries.MATERIAL AND METHODS: The survey is quantitative analytical cross-sectional study conducted in the period September - December 2013. Medical records from all patients on OST at national level during the year 2012 were analyzed. EMCDDA questionnaire from treatment protocol 3.0 was used. Data for OST patients on MMT was take from all 12 public treatment facilities, three private centers and 3 prisons. Data for OST patients on buprenorphine was taken from public clinic as the only one responsible for this type of treatment.RESULTS: A comprehensive network, diverse models of treatment intervention exists in the MKD. Total number of OST patients in 2012 in all treatment facilities was 1857 (1356 are in public, 141 in private, 360 in prison settings) 10% are on Buprenorphine and 90% are on Methadone, 52% in age group 20-34. Ratio of male to female heroin clients is 9:1; 162 are female (9 %); 107(66%) are in treatment in the age group 20-34. Average number of OST patients is 0.1% of the total population in each of the 10 cities analyzed. The mean age at first heroin use is 18 years. 40% of patients haven’t high school. With their family lives 65% of OST patients; 487 patients (36%) have children; 80% of patients use of benzodiazepines.CONCLUSION: Although treatment network of drug addiction is quite developed, perceived need for further capacity building and increase the quality of medical care implies increasing the availability, diversification in terms of sensitivity to cultural differences, gender, age, ethnicity, as well as the treatment of dependence of different types of psychoactive substances.

Cost-effectiveness of Methadone Maintenance Treatment in Prevention of HIV Among Drug Users in Shiraz, South of Iran

Background:

The increase in high-risk injections and unsafe sexual behaviors has led to increased HIV infection prevalence among Intravenous Drug Users (IDUs). The high costs of HIV/AIDS care and low financial resources necessitate an economic evaluation to make the best decision for the control of HIV/AIDS.

Objectives:

This study was conducted to determine the cost-effectiveness of Methadone Maintenance Treatment (MMT) centers in HIV infection prevention among drug users.

Materials and Methods:

In this interventional study, we included all the seven MMT centers and the drug users registered there (n = 694). We calculated all the costs imposed on the government, i.e. Provider of case. Mathematical models were used to estimate the number of HIV cases averted from high-risk behaviors. Sensitivity analyses were performed to show the effects of uncertainty in parameters on the number of HIV cases averted and also Incremental Cost-Effectiveness Ratio (ICER).

Results:

Based on the averted models, the selected MMT centers could prevent 128 HIV cases during 1 year. The total cost was $ 547423 and that of HIV/AIDS care in the no intervention scenario was estimated $ 14171816. ICER was $ 106382 per HIV case averted. The results of the sensitivity analysis indicated that MMT intervention was cost-effective even in the worst scenario and ICER varied from $ 39149 to $ 290004 per HIV case averted.

Conclusions:

With regard to the high prevalence of drug injection among drug users and considering the high effectiveness and cost-effectiveness of MMT centers in preventing HIV infection, establishment of MMT centers in regional and national levels seems reasonable.

Higher methadone doses are associated with lower mortality in patients of opioid dependence in Taiwan

Optimal methadone dosage and service profile is challenging in treatment of opioid dependence. This study explores the impact of methadone dosage on the mortality of opioid-dependent patients in methadone maintenance therapy by using a large-scale and continual supervised dosing registry information system. Database of nationwide enrolled opioid-dependent patients at methadone clinics in Taiwan during 2006-2008 was assessed. The relative risk of age, sex, marital status, HIV infection and methadone dosage were analyzed by Cox regression analysis. Among all of the 33,549 recruited patients, the crude mortality rate was 134.78/10,000 person-years, and the standardized mortality ratio was 4.68. A dose-response relationship of higher- vs. lower-dosage groups on the risk of mortality risk was observed (adjusted HR = 0.68, P = 0.016). In further sub-grouping analysis, this trend was more significant in HIV positive patients, in subgroup of patients who continuously staying in MMT, and in subgroup of patients who re-enter MMT. This dosage effect is not significantly seen in patients receiving MMT more than 365 days. Further exploration of other treatment-related factors may be important for understanding the long-term treatment outcome of opioid addiction patients.

Risk factors for fatal outcome in patients with opioid dependence treated with methadone in a family medicine setting in Croatia

AIM

To determine the risk factors for fatal outcome in patients with opioid dependence treated with methadone at the primary care level.

METHODS

A group of 287 patients with opioid dependence was monitored prospectively from 1995 to 2007. At the beginning of the study, we collected the data on patient baseline characteristics, treatment characteristics, and living environment. At the annual check-up, we collected the data on daily methadone dose, method of methadone therapy administration, and family physician's assessment of the patient's drug use status.

RESULTS

Out of 287 patients, 8% died. Logistic regression analysis showed that the predictors of fatal outcome were continuation of drug use during previous therapeutic attempts (odds ratio [OR], 19.402; 95% confidence interval [CI], 1.659-226.873), maintenance therapy as the planned treatment modality (OR, 3.738; 95% CI, 1.045-13.370), living in an unstable relationship (OR, 9.275; 95% CI, 2.207-38.984), and loss of continuity of care (OR, 12.643; 95% CI, 3.001-53.253).

CONCLUSION

The patients presenting these risk factors require special attention. It is important for family physicians to insist on compliance with the treatment protocol and intervene when they lose contact with the patient to prevent the fatal outcome.

Structural barriers in the context of opiate substitution treatment in Germany--a survey among physicians in primary care

Background

Opiate substitution treatment (OST) is the most widely used treatment for opioid dependence in Germany with substantial long-term benefits for the patient and for society. Due to lessened restrictive admission criteria, the number of registered OST patients in Germany has increased continuously in the recent years, whereas the number of physicians providing OST has remained constant. Previous data already indicated a deteriorating situation in the availability or quality of OST delivered and that structural barriers impede physicians in actively providing OST. The present survey among a sample of primary care physicians in Germany aimed to identify and assess potential structural barriers for the provision of health care in the context of OST.

Methods

An anonymous written questionnaire was sent out to a sample of 2,332 physicians across Germany providing OST. Physicians contacted were identified through databases of the Federal State Chambers of Physicians and/or of the Federal Associations of Statutory Health Insurance Physicians. Data obtained were analysed descriptively.

Results

The response rate was 25,5% and the majority of 596 physicians sampled viewed substantial problems in terms of the regulatory framework of OST care in the German context. Furthermore, financial remuneration, insufficient qualification, as well as inadequate interdisciplinary cooperation in the treatment of comorbidities of opiate substituted patients were regarded as problematic. The number of physicians providing OST in Germany is expected to substantially decrease in the near future.

Conclusion

Despite less restrictive admission criteria for OST in Germany, the legal regulation framework for OST is still a limiting factor through raising concerns on the provider and consumer side to be unable to adhere to the strict rules. To avoid future shortages in the provision of OST care on the system level in Germany, revisions to the legal framework seem to be necessary. In regards to adequate care for drug use-related infectious diseases and psychiatric comorbidities commonly found in opiate substituted patients, efforts are required to improve professional qualifications of physicians providing OST as well as respective interdisciplinary collaboration.

Changes in the characteristics and levels of comorbidity among new patients into methadone maintenance treatment program in British Columbia during its expansion period from 1998-2006

We described the changing characteristics and comorbidity levels of new patients into Methadone maintenance treatment (MMT) program in British Columbia, Canada, during its expansion period of 1998-2006. Analyses used administrative data. Generalized regression models were applied using Charlson Comorbidity Index (CCI) and Chronic Disease Score (CDS) as outcomes. 12,615 individuals initiated MMT during 1998-2006, while their odds of having moderate CCI (1 ≤ CCI ≤ 4) and mean CDS increased by 60% and 11%, respectively, after adjusting for confounders. MMT entrants were presented with progressively higher levels of comorbidity, independent of other characteristics. Future MMT policies should address higher levels of comorbidity among new patients.

Increased somatic morbidity in the first year after leaving opioid maintenance treatment: results from a Norwegian cohort study

BACKGROUND/AIMS

Some patients on opioid maintenance treatment (OMT) leave treatment temporarily or permanently. This study investigated whether patients interrupting their OMT differed from non-interrupters in sociodemographic and drug-use characteristics and examined acute/sub-acute somatic morbidity among the interrupters, prior to, during, and after OMT.

METHODS

Cohort design. OBSERVATION PERIOD: 5 years prior to, up to first 5 years during, and up to 5 years after interruption of OMT.

PARTICIPANTS

The sample (n = 200) comprised 51 OMT interrupters and 149 non-interrupters. Data on patient characteristics were obtained from interviews and OMT register information. Data on somatic morbidity were gathered from hospital records.

MEASUREMENTS

Key patient characteristics among OMT interrupters and non-interrupters. Incidence rates of acute and sub-acute somatic disease incidents leading to hospital treatment (drug-related/non-drug-related/injuries) prior to/during/after OMT.

RESULTS

Interrupters and non-interrupters did not differ in sociodemographic characteristics, while longer duration of amphetamine and benzodiazepine dependence predicted OMT interruption. Interrupters scored significantly higher on drug-taking and overdose during OMT but still had a significant 41% reduction in drug-related treatment, episodes. After interruption of treatment, such episodes increased markedly and were 3.6 times more frequent during the first post-OMT year compared to the pre-OMT period (p < 0.001). This increase was highest during the first months after OMT interruption. 2-5 years after interruption there was no significant increase.

CONCLUSIONS

Increased somatic morbidity was found among OMT interrupters during the first year after OMT, and especially during the immediate post-treatment period.

Methadone induction in primary care (ANRS-Methaville): a phase III randomized intervention trial

Background

In France, the rapid scale-up of buprenorphine, an opioid maintenance treatment (OMT), in primary care for drug users has led to an impressive reduction in HIV prevalence among injecting drug users (IDU) but has had no major effect on Hepatitis C incidence. To date, patients willing to start methadone can only do so in a methadone clinic (a medical centre for drug and alcohol dependence (CSAPA) or a hospital setting) and are referred to primary care physicians after dose stabilization. This study aims to assess the effectiveness of methadone in patients who initiated treatment in primary care compared with those who initiated it in a CSAPA, by measuring abstinence from street opioid use after one year of treatment.

Methods/Design

The ANRS-Methaville study is a randomized multicenter non-inferiority control trial comparing methadone induction (lasting approximately 2 weeks) in primary care and in CSAPA. The model of care chosen for methadone induction in primary care was based on study-specific pre-training of all physicians, exclusion criteria and daily supervision of methadone during the initiation phase. Between January 2009 and January 2011, 10 sites each having one CSAPA and several primary care physicians, were identified to recruit patients to be randomized into two groups, one starting methadone in primary care (n = 147), the other in CSAPA (n = 48). The primary outcome of the study is the proportion of participants abstinent from street opioids after 1 year of treatment i.e. non-inferiority of primary care model in terms of the proportion of patients not using street opioids compared with the proportion observed in those starting methadone in a CSAPA.

Discussion

The ANRS-Methaville study is the first in France to use an interventional trial to improve access to OMT for drug users. Once the non-inferiority results become available, the Ministry of Health and agency for the safety of health products may change the the New Drug Application (NDA) of methadone and make methadone induction by trained primary care physicians possible.

The trial is registered with the French Agency of Pharmaceutical Products (AFSSAPS) under the number 2008-A0277-48, the European Union Drug Regulating Authorities Clinical Trials.

Number Eudract 2008-001338-28, the ClinicalTrials.gov Identifier: NCT00657397 and the International Standard Randomised Controlled Trial Number Register ISRCTN31125511.

Harm reduction--from a conceptual framework to practical experience: the example of Germany

Drug demand reduction programs must be integrated into a comprehensive strategy aiming at preventing drug misuse, facilitating access to counseling, to treatment of dependence, and to rehabilitation; and establishing effective measures to reduce the adverse health and social consequences of drug misuse. The continuous and even rising spread of HIV/AIDS and other infectious diseases (e.g., hepatitis B and C) among injecting drug users is alarming. Although, in many countries the prevalence of HIV infections is decreasing due to the implementation of effective harm reduction measures, such as syringe exchange and opiate substitution treatment (OST), in other countries infections are on the rise. The lessons learnt indicate that only a comprehensive, evidence-based approach in prevention, treatment, care, and support is promising in combating the devastating effects of drug dependence.

Naltrexone extended-release injection: an option for the management of opioid abuse

The United States Food and Drug Administration (FDA) approved naltrexone, a synthetic competitive antagonist at opioid receptors, in oral form in 1984 for use in the management of opioid abuse and addiction. Because naltrexone and its major metabolite, 6-β-naltrexone, are both competitive antagonists at opioid receptors - and thereby inhibit opioid agonist-induced effects including those desired by abusers - it was hypothesized that once maintained on naltrex-one, opioid-induced desirable effects would be diminished to the point that relapse to illicit use would decline because it was no longer rewarding. However, good medication compliance is a requisite for such a strategy to be effective and a systematic review of oral naltrexone concluded that this method of treatment was not superior for any outcomes measured (ie, retention, abstinence, or side effects) to placebo, psychotherapy, benzodiazepines, or buprenorphine treatment. In addition, the retention rate on oral naltrexone was very low (less than 30%). Recently, the FDA approved an extended-release formulation (intramuscular depot injection) of naltrexone for prevention of relapse to opioid dependence following opioid detoxification and to be used along with counseling and social support. Since it needs to be administered only monthly, as opposed to the daily administration required for the oral formulation, naltrexone injection has the potential for increasing adherence and retention rates. Concerns include liver damage at high doses (oral formulation) and possible opioid overdose if an attempt is made to surmount receptor antagonism by taking higher doses of an opioid agonist or if opioid receptors become "sensitized" under long-term antagonism. The focus of the present review is the current information regarding the safety and efficacy of naltrexone extended-release therapy.

Health related quality of life trajectories of patients in opioid substitution treatment

BACKGROUND

While opioid substitution treatment (OST) provides the opportunity for substantial improvements in health related quality of life (HRQoL), this relationship is seldom documented and poorly understood. Our objectives were to identify differences in trajectories of HRQoL among chronic opioid-dependent patients and factors associated with improvement and deterioration in HRQoL following enrolment in opioid substitution treatment.

METHODS

In the North American Opiate Medication Initiative (NAOMI) randomized controlled trial, the Euroqol (EQ-5D) and other measures of demographic, health and drug use characteristics were collected at baseline and quarterly follow-up. Latent class growth analysis was applied to identify classes of HRQoL trajectories during treatment, while baseline correlates of class membership and factors associated with changes in HRQoL were identified in multivariate analyses.

RESULTS

Three classes of individual HRQoL growth trajectories were identified: class 1: low and constant (19.5%), class 2: moderate and improved (61.2%), and class 3: high and constant (19.3%). Class 1 members were younger and more likely to be female, while class 3 members were less likely to have chronic conditions and had lower illicit drug use severity at baseline. Changes in HRQoL were associated with improvements in housing status (positive), medical events (negative) and decreases in illicit drug use (positive).

CONCLUSIONS

Insight into the extent of HRQoL response and characteristics of patients responding to treatment can be used to design interventions that maximize HRQoL improvement. Given its role in economic evaluation and subsequent resource allocation decisions, HRQoL should be considered an endpoint in treatment evaluations for opioid dependence.

Effectiveness of buprenorphine maintenance treatment as compared to a syringe exchange program among buprenorphine misusing opioid-dependent patients

AIMS

To investigate the effectiveness of buprenorphine maintenance treatment (BMT) among opioid dependents who are mainly misusing buprenorphine intravenously.

METHODS

The study was a prospective naturalistic follow-up with a non-randomized control group. In Finland, 30 opioid dependents reporting previous misuse of buprenorphine and participating in the outpatient BMT and 30 matched controls participating in a syringe exchange program (SEP) were followed. Based on the evidence for the superiority of maintenance treatment, randomization was not done. The effectiveness was evaluated by retention rate, European Addiction Severity Index (EuropASI) interviews, Beck Depression Inventory (BDI), visual analogue scale for quality of life (VAS) during the 2-year follow-up and mortality rates during the 3-year follow-up. Because of drop-outs in the SEP group, only the BMT group was interviewed at 24 months.

RESULTS

At 3 months, the retention rate of the BMT group was 100% and of the SEP group 47%. At 12 months, the corresponding percentages were 83% and 37%. The total EuropASI composite score improved significantly only in the BMT group. In the BMT group, the BDI total score and VAS scales for quality of life improved significantly more than they did in the SEP group. During 3-year follow-up, four patients in the SEP died and none in the BMT.

CONCLUSIONS

BMT appears to be an effective treatment for opioid dependents using mainly buprenorphine intravenously. On the other hand, bare SEP appears to result in high drop-out, not significant improvements and deaths.

Cognitive functioning in opioid-dependent patients treated with buprenorphine, methadone, and other psychoactive medications: stability and correlates

BACKGROUND

In many but not in all neuropsychological studies buprenorphine-treated opioid-dependent patients have shown fewer cognitive deficits than patients treated with methadone. In order to examine if hypothesized cognitive advantage of buprenorphine in relation to methadone is seen in clinical patients we did a neuropsychological follow-up study in unselected sample of buprenorphine- vs. methadone-treated patients.

METHODS

In part I of the study fourteen buprenorphine-treated and 12 methadone-treated patients were tested by cognitive tests within two months (T1), 6-9 months (T2), and 12-17 months (T3) from the start of opioid substitution treatment. Fourteen healthy controls were examined at similar intervals. Benzodiazepine and other psychoactive comedications were common among the patients. Test results were analyzed with repeated measures analysis of variance and planned contrasts. In part II of the study the patient sample was extended to include 36 patients at T2 and T3. Correlations between cognitive functioning and medication, substance abuse, or demographic variables were then analyzed.

RESULTS

In part I methadone patients were inferior to healthy controls tests in all tests measuring attention, working memory, or verbal memory. Buprenorphine patients were inferior to healthy controls in the first working memory task, the Paced Auditory Serial Addition Task and verbal memory. In the second working memory task, the Letter-Number Sequencing, their performance improved between T2 and T3. In part II only group membership (buprenorphine vs. methadone) correlated significantly with attention performance and improvement in the Letter-Number Sequencing. High frequency of substance abuse in the past month was associated with poor performance in the Letter-Number Sequencing.

CONCLUSIONS

The results underline the differences between non-randomized and randomized studies comparing cognitive performance in opioid substitution treated patients (fewer deficits in buprenorphine patients vs. no difference between buprenorphine and methadone patients, respectively). Possible reasons for this are discussed.

Changes in somatic disease incidents during opioid maintenance treatment: results from a Norwegian cohort study

Objectives To examine the effect of opioid maintenance treatment (OMT) on somatic morbidity in a cohort of OMT patients. Design Retrospective cohort study. Setting OMT programme in two Norwegian counties. Participants 200 OMT patients, participation rate 71.2%. Main outcome measures Incidence rates (IR) before, during and after OMT for acute/subacute hospital-treated somatic disease incidents (drug-related, non-drug-related, injuries) and rates for inpatient days and outpatient treatment contacts. Results IR for drug-related hospital treatment episodes were 76% lower during compared to before OMT (before versus during incidence rate ratio (IRR) 4.2 (95% CI 2.9 to 6.2), p<0.001) and 11 times higher after compared to during OMT (after versus during IRR 11.1 (6.6 to 18.5), p<0.001). For non-drug-related treatment episodes, IR were 35% higher during than before OMT (before versus during IRR 0.7 (0.6 to 1.0), p=0.02) and 32% higher after compared to during OMT (IRR 1.4 (0.9 to 2.2), p=0.15), while injuries showed little change according to OMT status. Although patients with on-going drug-taking during OMT showed less reduction in drug-related hospital-treated incidents during treatment than patients not using illicit drugs, the quartile with most drug-taking showed a significant reduction (before versus during IRR 3.6 (2.4 to 5.3)). Patients who had experienced cessation of OMT showed a significant reduction in drug-related treatment episodes during OMT (before versus during IRR 1.7 (1.0 to 2.9)), although less than patients without OMT interruptions (before versus during IRR 6.1 (3.6 to 10.6)), and a significant increase after OMT cessation compared with during OMT (IRR 5.4 (3.0 to 9.7)). Conclusion Acute/subacute drug-related somatic morbidity is reduced during compared to before OMT. This was also found for patients with on-going drug-taking during OMT. However, acute drug-related health problems show an increase after OMT cessation, and this is a matter of concern. Further studies on somatic morbidity after OMT cessation should be carried out.

Deaths of opiate/opioid misusers involving dihydrocodeine, UK, 1997-2007

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Dihydrocodeine (DHC) is an opioid analgesic sometimes prescribed as an alternative to other medications (e.g. methadone and buprenorphine) for opioid misuse. Its effectiveness is, however, still controversial. DHC prescription rates seem to be related to levels of DHC fatalities, possibly in relation to levels of disregard of the availability of supervised or interval dispensing of opioids, but no large-scale analysis of DHC fatalities has been carried out. We analysed here involvement of DHC in fatalities that occurred between 1997 and 2007 among individuals with a history of opiate/opioid misuse reported to the National Programme on Substance Abuse Deaths (np-SAD).

WHAT THIS STUDY ADDS

DHC, either alone or in combination, was identified in 584 fatalities. Typical cases identified were males in their early thirties. In accidental overdoses, DHC, which had been prescribed to 45% of the victims, was typically identified in combination with other drugs, such as heroin/morphine, methadone and hypnotics/sedatives. Both paracetamol and antidepressants were more typically identified in combination with DHC in suicides. Opiate/opioid misusers should be educated about risks associated with polydrug intake and prescribers should carefully consider a pharmacological intervention alternative to DHC (e.g. methadone, buprenorphine) when managing and treating opiate addiction.

AIMS

Although its effectiveness is somewhat controversial, it appears that dihydrocodeine (DHC) is still prescribed in the UK as an alternative to both methadone and buprenorphine for the treatment of opiate addiction.

METHODS

Data covering the period 1997-2007 voluntarily supplied by coroners were analysed. All cases pertaining to victims with a clear history of opiate/opioid misuse and in which DHC, either on its own or in combination, was identified at post-mortem toxicology and/or implicated in death, were extracted from the database.

RESULTS

Dihydrocodeine, either alone or in combination, was identified in 584 fatalities meeting the selection criteria. In 44% of cases it was directly implicated in the cause of death. These cases represented about 6.8% of all opiate/opioid-related deaths during this period. Typical DHC cases identified were White males in their early thirties. Accidental deaths (96%) were likely to involve DHC in combination with other psychoactives, mainly heroin/morphine, hypnotics/sedatives and methadone. Both paracetamol and antidepressants were found in proportionately more suicide cases than in accidental overdoses. DHC had been prescribed to the decedent in at least 45% of cases.

CONCLUSIONS

Opiate/opioid misusers should be educated about risks associated with polydrug intake. More in particular, co-administration of DHC with heroin, methadone and benzodiazepines may increase the risk of accidental fatal overdose. Prescribers should carefully consider pharmacological intervention alternative to DHC (e.g. methadone, buprenorphine) when managing and treating opiate addiction. More resources are required to do prospective research in this area.

The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of substance use and related disorders. Part 2: Opioid dependence

OBJECTIVES

To develop evidence-based practice guidelines for the pharmacological treatment of opioid abuse and dependence.

METHODS

An international task force of the World Federation of Societies of Biological Psychiatry (WFSBP) developed these practice guidelines after a systematic review of the available evidence pertaining to the treatment of opioid dependence. On the basis of the evidence, the Task Force reached a consensus on practice recommendations, which are intended to be clinically and scientifically meaningful for physicians who treat adults with opioid dependence. The data used to develop these guidelines were extracted primarily from national treatment guidelines for opioid use disorders, as well as from meta-analyses, reviews, and publications of randomized clinical trials on the efficacy of pharmacological and other biological treatments for these disorders. Publications were identified by searching the MEDLINE database and the Cochrane Library. The literature was evaluated with respect to the strength of evidence for efficacy, which was categorized into one of six levels (A-F).

RESULTS

There is an excellent evidence base supporting the efficacy of methadone and buprenorphine or the combination of buprenorphine and naloxone for the treatment of opioid withdrawal, with clonidine and lofexidine as secondary or adjunctive medications. Opioid maintenance with methadone and buprenorphine is the best-studied and most effective treatment for opioid dependence, with heroin and naltrexone as second-line medications.

CONCLUSIONS

There is enough high quality data to formulate evidence-based guidelines for the treatment of opioid abuse and dependence. This task force report provides evidence for the efficacy of a number of medications to treat opioid abuse and dependence, particularly the opioid agonists methadone or buprenorphine. These medications have great relevance for clinical practice.

The vicious circle of perceived stigmatization, depressiveness, anxiety, and low quality of life in substituted heroin addicts

BACKGROUND

Perceived stigmatization of drug addicts may interact with negative mood states and thus may contribute to the maintenance of addictive behavior.

METHODS

Opiate maintenance patients (n = 106) and an unselected comparison group (n = 144) rated self-report questionnaires about perceived stigmatization, quality of life (QoL), depressiveness, anxiety, self-esteem, addiction characteristics, and social support.

RESULTS

63% of opiate maintenance patients felt discriminated in contrast to 16% of the comparison group. Perceived stigmatization was rated higher by opiate maintenance patients, and all domains of QoL were rated lower, even when statistically controlling depressiveness, anxiety and social factors. Perceived stigmatization was correlated to depressiveness, anxiety, low self-esteem and low QoL, but not addiction characteristics and social support. Structural equation models revealed anxiety and the pathway depressiveness enhancing feelings of being stigmatized resulting in low self-esteem to explain 74% of variance in mental QoL, whereas anxiety and a pathway stigmatization inducing depressiveness leading to low self-esteem explained 49% of variance in physical QoL.

CONCLUSIONS

A vicious circle of stigmatization, negative affective states and low QoL was confirmed. In addition to societal antistigma campaigns, antidepressive and anxiolytic therapy might have the potential to diminish feelings of being stigmatized and to improve QoL.

[Quality of life among patients in drug-assisted rehabilitation programmes]

BACKGROUND

Drug-assisted rehabilitation programmes reduce mortality and improve somatic and mental health among opioid abusers. We have explored changes in patients' perception of their QoL (quality of life) after enrollment in such a programme, and their explanations for these changes.

MATERIAL AND METHODS

26 patients, enrolled a drug-assisted rehabilitation programme, were interviewed according to a semi-structured guide. Changes in QoL were recorded on a five-point scale; from much worse to much better. Answers to the question "What are your two main explanations for improved/reduced QoL?" were recorded literally and analysed by systematic text condensation.

RESULTS

The informants made 42 statements on reasons for improved QoL and six for reduced QoL. Important explanations for improved QoL were that life is no longer ruled by addiction, fewer social problems, and improved relationships to family and friends. Improved physical and psychological health was rarely mentioned. Loneliness and isolation, as well as the control imposed on them by the programme were explanations for reduced QoL.

INTERPRETATION

A large majority of patients experienced improved QoL, and having regained control of their life was the most important explanation. Some felt the treatment dominated their life too much, and therefore expressed a poorer QoL.