1
|
Nordgren J, Monwell B, Johnson B, Gunnarsson NV, Capusan AJ. Healthcare staff's perspectives on long-acting injectable buprenorphine treatment: a qualitative interview study. Addict Sci Clin Pract 2024; 19:25. [PMID: 38581022 PMCID: PMC10996245 DOI: 10.1186/s13722-024-00458-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/25/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Long-acting injectable buprenorphine (LAIB) formulations are a novel treatment approach in opioid agonist treatment (OAT), which provide patients with a steady dose administered weekly or monthly and thus reduce the need for frequent clinic visits. Several studies have analyzed patient experiences of LAIB but the perspective of OAT staff is unknown. This study aimed to explore how healthcare staff working in OAT clinics in Sweden perceive and manage treatment with LAIB. METHODS Individual qualitative interviews were conducted with OAT physicians (n = 10) in tandem with nine focus group sessions with OAT nurses and other staff categories (n = 41). The data was analyzed with thematic text analysis. RESULTS Five central themes were identified in the data: (1) advantages and disadvantages of LAIB, (2) patient categories that may or may not need LAIB, (3) patients' degrees of medication choice, (4) keeping tabs, control and treatment alliance, and (5) LAIB's impact on risk and enabling environments in OAT. Overall staff found more advantages than disadvantages with LAIB and considered that patients with ongoing substance use and low adherence were most likely to benefit from LAIB. However, less frequent visits were viewed as problematic in terms of developing a treatment alliance and being able to keep tabs on patients' clinical status. Clinics differed regarding patients' degrees of choice in medication, which varied from limited to extensive. LAIB affected both risk and enabling environments in OAT. CONCLUSIONS LAIB may strengthen the enabling environment in OAT for some patients by reducing clinic visits, exposure to risk environments, and the pressure to divert medication. A continued discussion about the prerequisites and rationale for LAIB implementation is needed in policy and practice.
Collapse
Affiliation(s)
- Johan Nordgren
- Department of Social Work, Malmö University, Nordenskiöldsgatan 1, 211 19, Malmö, Sweden.
| | - Bodil Monwell
- Department of Social Work, Jönköping University, Jönköping, Sweden
- Psychiatric clinic, County Hospital Ryhov, Jönköping, Sweden
| | - Björn Johnson
- School of Social Work, Lund University, Lund, Sweden
| | | | - Andrea Johansson Capusan
- Center for Social and Affective Neuroscience, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| |
Collapse
|
2
|
Johnson B, Monwell B, Capusan AJ. Long-acting injectable depot buprenorphine from a harm reduction perspective in patients with ongoing substance use and multiple psychiatric comorbidities: a qualitative interview study. Harm Reduct J 2024; 21:68. [PMID: 38528531 PMCID: PMC10964574 DOI: 10.1186/s12954-024-00984-1] [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: 12/06/2023] [Accepted: 03/07/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Long-acting injectable depot buprenorphine may increase access to opioid agonist treatment (OAT) for patients with opioid use disorder in different treatment phases. The aim of this study was to explore the experiences of depot buprenorphine among Swedish patients with ongoing substance use and multiple psychiatric comorbidities. METHOD Semi-structured qualitative interviews were conducted with OAT patients with experience of depot buprenorphine. Recruitment took place at two OAT clinics with a harm reduction focus, specializing in the treatment of patients with ongoing substance use and multiple comorbidities. Nineteen participants were included, 12 men and seven women, with a mean age of 41 years (range 24-56 years), and a mean of 21 years (5-35 years) of experience with illicit substance use. All participants had ongoing substance use and psychiatric comorbidities such as ADHD, anxiety, mood, psychotic and eating disorders. Interviews were transcribed verbatim. Thematic content analysis was conducted both manually and using qualitative data analysis software. RESULTS Participants reported social benefits and positive changes in self-perception and identity. In particular, depot buprenorphine contributed to a realization that it was possible to make life changes and engage in activities not related to substance use. Another positive aspect that emerged from the interviews was a noticeable relief from perceived pressure to divert OAT medication, while some expressed the lack of income from diverted oral/sublingual OAT medication as a negative, but still acceptable, consequence of the depot buprenorphine. Many participants considered that the information provided prior to starting depot buprenorphine was insufficient. Also, not all patients found depot buprenorphine suitable, and those who experienced coercion exhibited particularly negative attitudes towards the medication. CONCLUSIONS OAT patients with ongoing substance use and multiple psychiatric comorbidities reported clear benefits of depot buprenorphine, including changes in self-perception which has been theorized to play an important role in recovery. Clinicians should consider the specific information needs of this population and the extensive diversion of traditional OAT medications in this population to improve the treatment experience and outcomes. Overall, depot buprenorphine is a valuable treatment option for a population in need of harm reduction and may also contribute to psychological changes that may facilitate recovery in those with the greatest need.
Collapse
Affiliation(s)
- Björn Johnson
- School of Social Work, Lund University, Lund, Sweden.
| | - Bodil Monwell
- Department of Psychiatry, County Hospital Jönköping, Jönköping, Sweden
- Department of Social Work, Jönköping University, Jönköping, Sweden
| | - Andrea Johansson Capusan
- Department of Psychiatry in Linköping, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Center for Social and Affective Neuroscience, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| |
Collapse
|
3
|
ElShebiney S, Elgohary R, El-Shamarka M, Mowaad N, Abulseoud OA. Natural Polyphenols-Resveratrol, Quercetin, Magnolol, and β-Catechin-Block Certain Aspects of Heroin Addiction and Modulate Striatal IL-6 and TNF-α. TOXICS 2023; 11:379. [PMID: 37112606 PMCID: PMC10145039 DOI: 10.3390/toxics11040379] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 04/04/2023] [Accepted: 04/14/2023] [Indexed: 06/19/2023]
Abstract
We have examined the effects of four different polyphenols in attenuating heroin addiction using a conditioned place preference (CPP) paradigm. Adult male Sprague Dawley rats received heroin (alternating with saline) in escalating doses starting from 10 mg/kg, i.p. up to 80 mg/kg/d for 14 consecutive days. The rats were treated with distilled water (1 mL), quercetin (50 mg/kg/d), β-catechin (100 mg/kg/d), resveratrol (30 mg/kg/d), or magnolol (50 mg/kg/d) through oral gavage for 7 consecutive days, 30 min before heroin administration, starting on day 8. Heroin withdrawal manifestations were assessed 24 h post last heroin administration following the administration of naloxone (1 mg/kg i.p). Heroin CPP reinstatement was tested following a single dose of heroin (10 mg/kg i.p.) administration. Striatal interleukin 6 (IL-6) and tumor necrosis factor alpha (TNF-α) were quantified (ELISA) after naloxone-precipitated heroin withdrawal. Compared to the vehicle, the heroin-administered rats spent significantly more time in the heroin-paired chamber (p < 0.0001). Concomitant administration of resveratrol and quercetin prevented the acquisition of heroin CPP, while resveratrol, quercetin, and magnolol blocked heroin-triggered reinstatement. Magnolol, quercetin, and β-catechin blocked naloxone-precipitated heroin withdrawal and increased striatal IL-6 concentration (p < 0.01). Resveratrol administration was associated with significantly higher withdrawal scores compared to those of the control animals (p < 0.0001). The results of this study show that different polyphenols target specific behavioral domains of heroin addiction in a CPP model and modulate the increase in striatal inflammatory cytokines TNF-α and IL-6 observed during naloxone-precipitated heroin withdrawal. Further research is needed to study the clinical utility of polyphenols and to investigate the intriguing finding that resveratrol enhances, rather than attenuates naloxone-precipitated heroin withdrawal.
Collapse
Affiliation(s)
- Shaimaa ElShebiney
- Department of Narcotics, Ergogenics, and Poisons, National Research Centre, Dokki, Cairo 12622, Egypt
| | - Rania Elgohary
- Department of Narcotics, Ergogenics, and Poisons, National Research Centre, Dokki, Cairo 12622, Egypt
| | - Marwa El-Shamarka
- Department of Narcotics, Ergogenics, and Poisons, National Research Centre, Dokki, Cairo 12622, Egypt
| | - Noha Mowaad
- Department of Narcotics, Ergogenics, and Poisons, National Research Centre, Dokki, Cairo 12622, Egypt
| | - Osama A. Abulseoud
- Department of Psychiatry and Psychology, Mayo Clinic, Phoenix, AZ 85001, USA
- Department of Neuroscience, Graduate School of Biomedical Sciences, Mayo Clinic College of Medicine, Phoenix, AZ 85001, USA
| |
Collapse
|
4
|
Clay S, Treloar C, Degenhardt L, Grebely J, Christmass M, Gough C, Hayllar J, McDonough M, Henderson C, Crawford S, Farrell M, Marshall A. 'I just thought that was the best thing for me to do at this point': Exploring patient experiences with depot buprenorphine and their motivations to discontinue. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 115:104002. [PMID: 37003194 DOI: 10.1016/j.drugpo.2023.104002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 04/03/2023]
Abstract
INTRODUCTION Long-acting injectable depot buprenorphine is a recent addition to the suite of opioid agonist therapies (OAT) used to treat opioid use disorder (OUD). However, there has been little research that focuses on the lived experience of people receiving depot buprenorphine treatment and reasons for why people decide to discontinue. The aim of this study was to explore what it is like to receive depot buprenorphine and to understand the motivations behind why people discontinue. METHODS Open-ended, semi-structured interviews were conducted between November 2021 and January 2022 with individuals who were either currently receiving depot buprenorphine or had discontinued or were in the process of discontinuing depot buprenorphine. Liberati, et al.'s (2022) adaptation of Dixon-Woods's (2006) candidacy framework was used to analyse the participant experiences. RESULTS 40 participants (26 male, 13 female, 1 undisclosed; mean age 42 years) were interviewed about their experience with depot buprenorphine. At the time of the interview, 21 were currently receiving depot buprenorphine and 19 had discontinued this treatment or were in the process of discontinuing. Participants cited 4 key reasons why they decided to discontinue depot buprenorphine:1) feeling forced into the program, 2) experiencing negative side-effects, 3) finding the treatment ineffective, and 4) wanting to stop depot buprenorphine/OAT to use opioids again or feeling 'cured' and no longer in need of OAT. Participants were ultimately discussing issues related to clinician-patient power relations, agency and bodily autonomy, and the pursuit of well-being. CONCLUSION Depot buprenorphine remains a promising treatment for OUD and offers potential to improve treatment adherence. Instances of restricted OAT choice and consumer concerns regarding a lack of agency must be addressed in order to enhance therapeutic relationships. Clinicians and other healthcare workers in this field also need greater access to information about depot buprenorphine to better address issues patients face during treatment. More research is required to understand patient and treatment choice given the options of these new treatment formulations.
Collapse
Affiliation(s)
- Simon Clay
- National Drug & Alcohol Research Centre, University of New South Wales, Australia.
| | - Carla Treloar
- National Drug & Alcohol Research Centre, University of New South Wales, Australia
| | - Louisa Degenhardt
- National Drug & Alcohol Research Centre, University of New South Wales, Australia
| | - Jason Grebely
- National Drug & Alcohol Research Centre, University of New South Wales, Australia
| | - Michael Christmass
- National Drug & Alcohol Research Centre, University of New South Wales, Australia
| | - Chris Gough
- National Drug & Alcohol Research Centre, University of New South Wales, Australia
| | - Jeremy Hayllar
- National Drug & Alcohol Research Centre, University of New South Wales, Australia
| | - Mike McDonough
- National Drug & Alcohol Research Centre, University of New South Wales, Australia
| | - Charles Henderson
- National Drug & Alcohol Research Centre, University of New South Wales, Australia
| | - Sione Crawford
- National Drug & Alcohol Research Centre, University of New South Wales, Australia
| | - Michael Farrell
- National Drug & Alcohol Research Centre, University of New South Wales, Australia
| | - Alison Marshall
- National Drug & Alcohol Research Centre, University of New South Wales, Australia
| |
Collapse
|
5
|
Kline A, Williams JM, Steinberg ML, Mattern D, Chesin M, Borys S, Chaguturu V. Predictors of opioid overdose during the COVID-19 pandemic: The role of relapse, treatment access and nonprescribed buprenorphine/naloxone. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 149:209028. [PMID: 37003539 PMCID: PMC10063455 DOI: 10.1016/j.josat.2023.209028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 01/17/2023] [Accepted: 03/17/2023] [Indexed: 04/03/2023]
Abstract
INTRODUCTION Emerging data indicate a disproportionate increase in overdose deaths since the onset of COVID-19. Speculation about causes for the increase center on rising drug use, illicit drug supply changes, and reduced treatment access. Possible overdose mitigation factors include reduced federal MOUD prescribing restrictions, naloxone distribution programs, and increased use of telehealth. Similarly, nonprescribed buprenorphine (NPB) use, increasingly described as a harm reduction strategy in the absence of treatment, may have moderated overdose risk. This study explored factors associated with pandemic-related overdose in people who use opioids (PWUO) in New Jersey. METHODS We surveyed 342 PWUO from March to May 2021. Approximately 50 % of our sample was treated at some time since the COVID-19 emergency declaration in March 2020. The risk and protective factors associated with overdose were identified using Pearson's chi square test and ANOVA and tested in a series of multivariable logistic regression models for the full sample and the subsample of PWUO treated during the pandemic. RESULTS Forty-eight percent of respondents increased their drug use during the pandemic, including 32 % who relapsed after previous abstinence. Fifteen percent overdosed at least once since March 2020. In the full sample, overdose was associated with Hispanic ethnicity (AOR = 3.51; 95 % CI = 1.22-10.11), pre-pandemic overdose (AOR = 6.75; 95 % CI = 3.03-15.02), lack/loss of medical insurance (AOR = 3.02; 95 % CI = 1.01-9.02), relapse (AOR = 2.94; 95 % CI = 1.36-6.36), and nonprescribed use of buprenorphine/naloxone (AOR = 3.16; 95 % CI = 1.49-6.70). The study found similar trends in the treatment sample, with the exceptions that heroin/fentanyl use also predicted overdose (AOR = 3.43; 95 % CI = 1.20-9.78) and the association of overdose with nonprescribed buprenorphine/naloxone was stronger (AOR = 4.91; 95 % CI = 2.01-12.03). Potential mitigating factors, such as take-home methadone and telehealth, were not significant. CONCLUSIONS Relapse during the pandemic was widespread and a significant contributor to overdose. Lack/loss of medical insurance further exacerbated the risk. Despite the growing literature reporting "therapeutic" use of NPB, people using nonprescribed buprenorphine/naloxone in the current study experienced up to five times the risk of overdose as nonusers. This finding suggests that, despite therapeutic intent, PWUO may be using NPB in ways that are ineffectual for addiction management, especially in the context of changing buprenorphine induction protocols in the context of fentanyl.
Collapse
Affiliation(s)
- Anna Kline
- Rutgers-Robert Wood Johnson Medical School, Department of Psychiatry, 317 George Street, New Brunswick, NJ 08901, United States.
| | - Jill M Williams
- Rutgers-Robert Wood Johnson Medical School, Department of Psychiatry, 317 George Street, New Brunswick, NJ 08901, United States.
| | - Marc L Steinberg
- Rutgers-Robert Wood Johnson Medical School, Department of Psychiatry, 317 George Street, New Brunswick, NJ 08901, United States.
| | - Dina Mattern
- Rutgers-Robert Wood Johnson Medical School, Department of Psychiatry, 317 George Street, New Brunswick, NJ 08901, United States.
| | - Megan Chesin
- William Paterson University, 300 Pompton Road, Wayne, NJ 07470, United States
| | - Suzanne Borys
- New Jersey Department of Human Services, Division of Mental Health and Addiction Services, 222 S. Warren St., PO Box 700, Trenton, NJ 08625-0700, United States.
| | - Vamsee Chaguturu
- Rutgers-Robert Wood Johnson Medical School, Department of Psychiatry, 317 George Street, New Brunswick, NJ 08901, United States.
| |
Collapse
|
6
|
Johnson B, Flensburg OL, Capusan AJ. Patient perspectives on depot buprenorphine treatment for opioid addiction - a qualitative interview study. Subst Abuse Treat Prev Policy 2022; 17:40. [PMID: 35614466 PMCID: PMC9131643 DOI: 10.1186/s13011-022-00474-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Recently developed buprenorphine depot injections have the potential to reduce risk for diversion and misuse, and to increase adherence with fewer visits for supervised intake. However, it is unclear how patients perceive this new form of medication. The purpose of this study was to explore patients' experiences of depot injections and their reasons for continuing, discontinuing, or declining depot injection treatment. METHODS We conducted semi-structured qualitative interviews with 32 people, 14 of whom had ongoing depot injection treatment, 11 who had discontinued depot-injections and switched to other medication and seven who had declined treatment with depot formulations. Interviews were transcribed, coded, and analysed using NVivo, based on this overall stratification into three participant groups. RESULTS The main categories relate to the effects and side effects of the depot formulation, social and practical factors, psychological benefits and disadvantages, and interactions with treatment staff. Social and practical factors were of importance for choosing depot formulations, such as increased freedom and their making it easier to combine treatment with work and family life, as well as psychological advantages including "feeling normal". Initial withdrawal symptoms that resolved themselves after a number of injections were reported by most participants. Reliable information and patient-staff relationships characterized by trust helped patients to cope with these initial problems. Those who discontinued treatment often did so near the beginning of the treatment, reporting withdrawal symptoms and insufficient effects as the main reasons. Coercion and insufficient information contributed to a negative pharmaceutical atmosphere at one of the clinics, which may have adversely influenced perceptions of depot formulations and decreased willingness to accept and continue treatment. CONCLUSIONS Buprenorphine depot injections may have social, practical, and psychological benefits compared to other formulations. However, depot injections are not perceived as an attractive option by all patients. Trust, consistent and adequate information, and awareness of the implications of the pharmaceutical atmosphere should be considered when introducing new medications.
Collapse
Affiliation(s)
- Björn Johnson
- Department of Social Work, Malmö University, Malmö, Sweden.
| | | | - Andrea Johansson Capusan
- Department of Psychiatry in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Center for Social and Affective Neuroscience, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| |
Collapse
|
7
|
Stalund IV, Grønseth H, Reinholt FP, Svarstad E, Marti HP, Leh S. Chronic Kidney Disease from Polyvinylpyrrolidone Deposition in Persons with Intravenous Drug Use. Clin J Am Soc Nephrol 2022; 17:518-526. [PMID: 35296512 PMCID: PMC8993479 DOI: 10.2215/cjn.13681021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 02/17/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Persons with intravenous drug use have a higher risk of developing CKD compared with the general population. In Norway, deposits of polyvinylpyrrolidone have been observed in kidney biopsies taken from persons with opioid addiction and intravenous drug use since 2009. Polyvinylpyrrolidone is an excipient commonly used in pharmaceuticals, and the polyvinylpyrrolidone deposits observed in these patients were caused by intravenous injection of a specific oral methadone syrup containing very high molecular weight polyvinylpyrrolidone. Here, we present the clinicopathologic findings from 28 patients with CKD associated with polyvinylpyrrolidone deposition in the kidney. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The 28 patients and their kidney biopsies were included when polyvinylpyrrolidone deposition was recognized, either retrospectively or at the time of diagnostic evaluation. Biopsies were taken between 2009 and 2016. We collected laboratory parameters and clinical data from digital patient charts. For each kidney biopsy, the glomerular volume, extent of polyvinylpyrrolidone deposition, and tubulointerstitial area with tubular atrophy were assessed quantitatively. RESULTS All patients (mean age: 37 years) had CKD (mean eGFR: 33 ml/min per 1.73 m2) and normal urine protein or non-nephrotic-range proteinuria. Biopsies showed moderate to severe tubular atrophy (mean extent: 65%) and interstitial infiltrates of vacuolated macrophages containing polyvinylpyrrolidone (mean share of biopsy area: 1.5%). Underperfused and ischemic glomeruli were common findings. In 22 samples, ultrastructural investigation revealed polyvinylpyrrolidone-containing vacuoles in the mesangial or endothelial cells of glomeruli. At the last follow-up, most patients had stable or improved eGFR. Two patients had developed kidney failure and underwent hemodialysis. CONCLUSIONS Intravenous injection of a specific oral methadone syrup caused polyvinylpyrrolidone deposition in the kidney in persons with opioid addiction and intravenous drug use. Kidney biopsy findings suggested an association between polyvinylpyrrolidone deposition and tubular atrophy.
Collapse
Affiliation(s)
- Ida V Stalund
- Department of Pathology, Haukeland University Hospital, Bergen, Norway .,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Heidi Grønseth
- Department of Pathology, Haukeland University Hospital, Bergen, Norway
| | - Finn P Reinholt
- Department of Pathology, Oslo University Hospital, Oslo, Norway
| | - Einar Svarstad
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Hans-Peter Marti
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Sabine Leh
- Department of Pathology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| |
Collapse
|
8
|
Rostam-Abadi Y, Gholami J, Noroozi A, Ansari M, Baheshmat S, Hamzehzadeh M, Ghadirzadeh MR, Vahdani B, Ekhtiari H, Mojtabai R, Rahimi-Movaghar A. Public health risks associated with methadone in Iran: A systematic review and meta-analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 100:103529. [PMID: 34826790 DOI: 10.1016/j.drugpo.2021.103529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 09/25/2021] [Accepted: 10/30/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND There has been a marked growth in methadone maintenance treatment (MMT) in Iran in the past two decades with positive health outcomes. We conducted a systematic review of studies on the prevalence of non-prescribed methadone use, methadone use disorder, and methadone-related poisoning and mortality in Iran. METHODS We searched International and Iranian databases up to May 2020 and contacted relevant experts. The pooled proportions were estimated through random-effects model. Methadone-related adverse outcomes were evaluated over time. RESULTS Sixty-five studies were included. The pooled estimates of non-prescribed methadone use in the last 12-month were 2.7% (95%CI: 0.9-5.4) and 0.1% (95%CI: 0.03-0.2) in the male and female general population, respectively. Among people who use drugs, 8.4% reported daily non-prescribed use in 2018. Four heterogeneous studies in drug treatment centers reported the existence of treatment-seeking for methadone use disorder. Methadone was responsible for 10.4% (95%CI: 4.5-18.3) of cases of acute poisoning in adults and 16.0% (95%CI: 9.3-24.1) in children. Methadone was reported as a cause of death in 53.5% of substance-related deaths referred to the Legal Medicine Organization while being the only cause in 35.8% of all cases. CONCLUSION Non-prescribed use of methadone in the general population is much less than opiates and some other available prescription opioids, like tramadol. However, notwithstanding the large and successful MMT program in Iran, increasing trends in methadone-related poisoning and deaths pose serious public health concerns. There is an urgent need to explore these fatal and non-fatal poisoning cases and implement policies to curb the harms associated with methadone use.
Collapse
Affiliation(s)
- Yasna Rostam-Abadi
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran
| | - Jaleh Gholami
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Noroozi
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran
| | - Mina Ansari
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran
| | - Shahab Baheshmat
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran; Department of Neuroscience and Addiction Studies, School of Advanced Technologies in Medicine (SATiM), Tehran University of Medical Sciences, Tehran, Iran
| | - Marziyeh Hamzehzadeh
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran; Department of Neuroscience and Addiction Studies, School of Advanced Technologies in Medicine (SATiM), Tehran University of Medical Sciences, Tehran, Iran
| | | | - Bita Vahdani
- Center for Disease Affairs and Transplant, Ministry of Health, Tehran, Iran
| | - Hamed Ekhtiari
- Laureate Institute for Brain Research, Tulsa, Oklahoma, USA
| | - Ramin Mojtabai
- Department of Mental Health, Bloomberg School of Public Health and Department of Psychiatry, Johns Hopkins University, Baltimore, Maryland, USA
| | - Afarin Rahimi-Movaghar
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
9
|
Hesse M, Thylstrup B, Seid AK, Tjagvad C, Clausen T. A retrospective cohort study of medication dispensing at pharmacies: Administration matters! Drug Alcohol Depend 2021; 225:108792. [PMID: 34118551 DOI: 10.1016/j.drugalcdep.2021.108792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 03/26/2021] [Accepted: 03/27/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Opioid agonist treatment (OAT) for opioid use disorders may be delivered at treatment clinics or dispensed from pharmacies, however the type of delivery may be associated with different risks and benefits. The aim of the study was to investigate whether dispensing of methadone or buprenorphine at pharmacies during treatment for opioid use disorders was associated with adverse outcomes. METHODS Retrospective cohort study using a national, linked, population-level data set from Denmark. Patients included were between 18 and 75 years, living in Denmark, and admitted for treatment for opioid use disorders during 2000-2016 (n = 9299). Cox proportional hazards regression was estimated for convictions, non-fatal overdoses, and death, after the first dispensing of either methadone or buprenorphine from a pharmacy after starting treatment. FINDINGS Of all patients, 68 % had methadone and 31 % had buprenorphine dispensed at a pharmacy. Compared with the time prior to pharmacy dispension, the risk of criminal convictions increased after having methadone dispensed from a pharmacy (adjusted hazard ratio (aHR) = 1.22, 95 % confidence interval (CI) = 1.16-1.28), non-fatal overdoses (aHR = 1.55, CI 1.41-1.71), and all-cause mortality (aHR = 1.54, CI = 1.43-1.76). After having buprenorphine dispensed at a pharmacy, risk of criminal convictions increased (aHR = 1.08, CI = 1.01-1.16) and non-fatal overdoses (aHR = 1.31, CI = 1.18-1.45), but not all-cause mortality (aHR = 1.07, CI = 0.94-1.23). CONCLUSIONS For almost all outcomes investigated across medication type, the risk of adverse events increased following a switch from clinic dispension to pharmacy dispension of medications in OAT. Medically responsible and safe provision of OAT may often require more clinical follow-up than what is typically provided when medication is dispensed at pharmacies.
Collapse
Affiliation(s)
- Morten Hesse
- Center for Alcohol and Drug Research, Aarhus University, Bartholins Allé 10, 8000, Aarhus C, Denmark.
| | - Birgitte Thylstrup
- Center for Alcohol and Drug Research, Aarhus University, Bartholins Allé 10, 8000, Aarhus C, Denmark.
| | - Abdu Kedir Seid
- Center for Alcohol and Drug Research, Aarhus University, Bartholins Allé 10, 8000, Aarhus C, Denmark.
| | - Christian Tjagvad
- Norwegian Centre for Addiction Research (SERAF), University of Oslo, Bygg 45, Ullevål sykehus, Kirkeveien 166, 0450, Oslo, Norway.
| | - Thomas Clausen
- Norwegian Centre for Addiction Research (SERAF), University of Oslo, Bygg 45, Ullevål sykehus, Kirkeveien 166, 0450, Oslo, Norway.
| |
Collapse
|
10
|
Fugelstad A, Bremberg S, Hjelmström P, Thiblin I. Methadone-related deaths among youth and young adults in Sweden 2006-15. Addiction 2021; 116:319-327. [PMID: 32533568 DOI: 10.1111/add.15152] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 05/10/2020] [Accepted: 06/10/2020] [Indexed: 01/06/2023]
Abstract
AIMS To identify methadone-related deaths and determine the prevalence among youth and young adults in Sweden 2006-15. DESIGN, SETTING AND PARTICIPANTS National retrospective registry study comparing data from all forensic autopsy examinations and toxicology cases involving methadone during 2006-15 in individuals aged 15-29 years with police records, previous pharmaceutical prescriptions and health-care episodes. MEASUREMENTS Multinomial logistic regression. To assess the factors contributing to the deaths, we compared individuals with and without previous substance use treatment and opioid use-related diagnoses with regard to previous opioid agonist treatment (OAT), psychiatric care and previous pain medication. To assess the circumstances of deaths, we analyzed the presence of other drugs and other factors at time of death. FINDINGS We identified 269 methadone-related deaths, and the rate increased during the study period. Seventy-two (27%) cases had not previously received substance use treatment, 112 (42%) had received treatment but had no opioid use-related diagnosis and 85 (32%) had received treatment and had an opioid use-related diagnosis. In total, only 10 individuals had been prescribed methadone during the year before death. Prescriptions of benzodiazepines (60%), antidepressants (62%) and opioids for pain (22%) the year before death were common. Most deaths occurred during sleep with a time lag from ingestion of methadone. CONCLUSION Prescription opioid- and methadone-related deaths increased in the group aged 15-29 years in Sweden between 2006 and 2015. Exposure to non-prescribed methadone and prescribed benzodiazepines, antidepressants and opioids for pain appears to be common in drug-related deaths in youth and young adults in Sweden.
Collapse
Affiliation(s)
- Anna Fugelstad
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Sven Bremberg
- Department of Public Health, Karolinska Institute, Stockholm, Sweden
| | | | - Ingmar Thiblin
- Department of Surgical Sciences, Section for Forensic Medicine, Uppsala University, Uppsala, Sweden
| |
Collapse
|
11
|
Shapira B, Rosca P, Berkovitz R, Gorjaltsan I, Neumark Y. The switch from one substance-of-abuse to another: illicit drug substitution behaviors in a sample of high-risk drug users. PeerJ 2020; 8:e9461. [PMID: 32742781 PMCID: PMC7370931 DOI: 10.7717/peerj.9461] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 06/10/2020] [Indexed: 01/07/2023] Open
Abstract
Background Substitution can be defined as the consciously motivated choice to use one drug, either licit or illicit, instead of another, due to perceptions of cost, availability, safety, legality, substance characteristics, and substance attributions. Substitution represents a potential risk to drug users, mainly when substitutes are of higher potency and toxicity. This study offers a basic conceptualization of illicit substitution behavior and describes substitution patterns among users of two highly prevalent drugs of abuse-heroin and cannabis. Methods Here, 592 high-risk drug users undergoing pharmacological and psycho-social treatment were interviewed. Patients were asked questions about current drug use, lifetime substitution, and substitution patterns. Descriptive statistics, chi-square tests of independence, and multinomial logistic regressions were used to identify and test correlates of substitution patterns for heroin and cannabis. Results Of the 592 drug users interviewed, 448 subjects (75.7%) reported having substituted their preferred drug for another illicit substance. Interviews yielded a total of 275 substitution events reported by users of cannabis, and 351 substitution events reported by users of heroin. The most frequently reported substitution substances for responders who preferred heroin were illicit non-prescribed "street" methadone (35.9%), followed by oral and transdermal prescription opioids (17.7%). For responders who preferred cannabis, substitution for synthetic cannabinoid receptor agonists (33.5%) followed by alcohol (16.0%) were the most commonly reported. Age at onset-of-use (p < 0.005), population group (p = 0.008), and attending treatment for the first time (p = 0.026) were significantly associated with reported lifetime substitution. Past-year use of stimulants, heroin, hallucinogens, methylenedioxymethamphetamine (MDMA), and novel psychoactive substances were-at the 95% confidence level-also significantly associated with reported lifetime substitution. In multivariate analysis, the odds for methadone substitution among heroin users were significantly affected by age at onset-of-use, type of treatment center, and education. Odds for substitution for synthetic cannabinoid receptor agonists among cannabis users were significantly affected by age, population group, type of treatment center, and education. Conclusion Self-substitution behavior should be considered by clinicians and policymakers as a common practice among most drugusers. Substitution for street methadone provides evidence for the ongoing diversion of this substance from Opioid Maintenance Treatment Centers, while the prominence of substitution of synthetic cannabinoids among dual-diagnosis patients should be regarded as an ongoing risk to patients that needs to be addressed by clinicians. Analysis of additional substitution patterns should provide further valuable insights into the behavior of drugusers.
Collapse
Affiliation(s)
- Barak Shapira
- Braun School of Public Health and Community Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Division of Enforcement and Inspection, Israel Ministry of Health, Jerusalem, Israel
| | - Paola Rosca
- Department for the Treatment of Substance Abuse, Israel Ministry of Health, Jerusalem, Israel
| | - Ronny Berkovitz
- Division of Enforcement and Inspection, Israel Ministry of Health, Jerusalem, Israel
| | | | - Yehuda Neumark
- Braun School of Public Health and Community Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| |
Collapse
|
12
|
Bech AB, Clausen T, Waal H, Vindenes V, Edvardsen HE, Frost J, Skeie I. Post-mortem toxicological analyses of blood samples from 107 patients receiving opioid agonist treatment: substances detected and pooled opioid and benzodiazepine concentrations. Addiction 2020; 116:845-855. [PMID: 32738014 DOI: 10.1111/add.15211] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 11/30/2022]
Abstract
AIMS To present the substances and their concentrations detected post-mortem in patients receiving opioid agonist treatment (OAT) stratified by cause of death, estimate the pooled opioid and benzodiazepine concentrations using established conversion factors for blood concentrations from the Norwegian Road Traffic Act, and explore the association between drug-induced cause of death and the pooled opioid and benzodiazepine concentrations. DESIGN Cross-sectional nationwide study. SETTING Norway. PARTICIPANTS One hundred and seven patients who died during OAT (i.e. within 5 days after the last intake of OAT medication) between 1 January 2014 and 31 December 2015, with post-mortem femoral blood available for toxicology. Data were collected from hospital records, the Norwegian Cause of Death Registry and autopsy reports. MEASUREMENTS Presence of alcohol and non-alcohol substances in the bloodstream at time of death, determined through records of toxicology of post-mortem femoral blood. FINDINGS A median of four substances was detected across the causes of death. At least one benzodiazepine was detected in 81 (76%) patients. The median pooled opioid concentration was significantly higher in drug-induced deaths compared with other causes of death (362 ng/mL versus 182 ng/mL, P < 0.001), in contrast to the pooled benzodiazepine concentration (5466 versus 5701 ng/mL, P = 0.353). The multivariate regression analysis showed that only increasing pooled opioid concentration (ng/ML) was associated with increased odds of a drug-induced cause of death (odds ratio, 1.003; 95% confidence interval: 1.001-1.006). CONCLUSIONS In Norway, overall opioid concentration seems to play an important role in drug-induced deaths during opioid agonist treatment in patients prescribed methadone or buprenorphine. Patients prescribed buprenorphine tend to replace their agonist with full agonists, while patients prescribed methadone tend to have high opioid concentrations from methadone as the only opioid.
Collapse
Affiliation(s)
- Anne Berit Bech
- National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Department of Mental Health, P.O. Box 104, 2381, Brumunddal, Norway
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, 0318, Oslo, Norway
| | - Thomas Clausen
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, 0318, Oslo, Norway
| | - Helge Waal
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, 0318, Oslo, Norway
- National Advisory Unit on Substance Use Disorder Treatment, Oslo University Hospital, Sognsvannsveien 21, Bygg 6, P.O. Box 4959 Nydalen, 0424, Oslo, Norway
| | - Vigdis Vindenes
- Department of Forensic Sciences, Oslo University Hospital, P. O. Box 4950, 0424, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, P. O. Box 1171 Blindern, 0318, Oslo, Norway
| | - Hilde Erøy Edvardsen
- Department of Forensic Sciences, Oslo University Hospital, P. O. Box 4950, 0424, Oslo, Norway
| | - Joachim Frost
- Department of Clinical Pharmacology, St. Olav's Hospital Trondheim University Hospital, P.O. Box 3250 Torgarden, 7006, Trondheim, Norway
| | - Ivar Skeie
- National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Department of Mental Health, P.O. Box 104, 2381, Brumunddal, Norway
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, 0318, Oslo, Norway
| |
Collapse
|
13
|
Hyatt JM, Lobmaier PP. Medication assisted treatment (MAT) in criminal justice settings as a double-edged sword: balancing novel addiction treatments and voluntary participation. HEALTH & JUSTICE 2020; 8:7. [PMID: 32172481 PMCID: PMC7071668 DOI: 10.1186/s40352-020-0106-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 01/16/2020] [Indexed: 06/10/2023]
Abstract
Medication-Assisted Treatment (MAT) provides an opportunity to address opioid addiction among justice-involved individuals, an often difficult to reach population. This potential has been increasingly recognized by agencies, policymakers and pharmaceutical companies. The result has been a marked increase in the number of drug courts, prisons and agencies in which MAT, notably with long-acting injectable medications, is offered. While this is a positive development, ensuring that vulnerable individuals are in a position voluntarily participation within the complex criminal justice environment is necessary. The unequal authority and agency inherent in the nature of these environments should be recognized. Therefore, rigorous protections, mirroring the goals of the consent processes required for medical or sociobehavorial research, should be employed when MAT is offered to protect individual autonomy.
Collapse
Affiliation(s)
- Jordan M. Hyatt
- Department of Criminology and Justice Studies, Drexel University, 3141 Chestnut Street, Philadelphia, PA 19104 USA
| | - Philipp P. Lobmaier
- Norwegian Centre for Addiction Research, University of Oslo, Kirkeveien 166, building 49, Oslo, 0450 Norway
| |
Collapse
|
14
|
Andersson L, Håkansson A, Krantz P, Johnson B. Investigating opioid-related fatalities in southern Sweden: contact with care-providing authorities and comparison of substances. Harm Reduct J 2020; 17:5. [PMID: 31918732 PMCID: PMC6953255 DOI: 10.1186/s12954-019-0354-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 12/27/2019] [Indexed: 12/23/2022] Open
Abstract
Background Opioid-related deaths have increased in Western countries over recent decades. Despite numerous studies investigating opioid-related mortality, only a few have focused on the lives of the deceased individuals prior to their deaths, specifically regarding contact with care-providing authorities such as health, social and correctional services. Furthermore, a change has been noted in the last two decades as to which opioids cause most deaths, from heroin to prescription opioids. However, studies comparing fatalities caused by different substances are rare. The aim of this study was to investigate contact with care-providing authorities during the year prior to death among individuals who died as a result of opioid intoxication and to analyse differences relating to which opioids caused their deaths. Methods The study is based on retrospective register data and includes 180 individuals with a history of illicit drug use, who died from opioid intoxication in Skåne, Sweden, between 1 January 2012 to 31 December 2013 and 1 July 2014 to 30 June 2016. Intoxications caused by heroin, methadone, buprenorphine and fentanyl were included. Data were collected from the National Board of Forensic Medicine, regional health care services, municipal social services and the Prison and Probation Service. Statistical testing was performed using Pearson’s chi-square test, Fisher’s exact test and the Mann-Whitney U test to analyse group differences. Results A total of 89% of the deceased individuals had been in contact with one or more of the care-providing authorities during the year prior to death; 75% had been in contact with health care, 69% with the social services, 28% with the Prison and Probation Service, and 23% had been enrolled in opioid substitution treatment at some point during their final year of life. Few differences appeared between the substance groups with regard to which opioid contributed to the death. In addition to opioids, sedatives were present in more than 80% of the cases. Individuals whose deaths were buprenorphine-related had been in contact with the social services to a significantly lesser extent during the year prior to death. Conclusions The studied population is characterised by extensive contact with care-providing authorities, thus providing numerous opportunities for authorities to reach this group with preventive and other interventions. Few differences emerged between groups with regard to which opioid had contributed to the death.
Collapse
Affiliation(s)
- Lisa Andersson
- Department of Social Work, Faculty of Health and Society, Malmö University, Malmö, Sweden.
| | - Anders Håkansson
- Faculty of Medicine, Department of Clinical Sciences Lund, Psychiatry, Lund University, Lund, Sweden.,Malmö Addiction Centre, Region Skåne, Malmö, Sweden
| | - Peter Krantz
- Faculty of Medicine, Department of Clinical Sciences Lund, Forensic Medicine, Lund University, Lund, Sweden
| | - Björn Johnson
- Department of Social Work, Faculty of Health and Society, Malmö University, Malmö, Sweden
| |
Collapse
|
15
|
Sarkar S, Varshney M, Patil V, Lal R. Maintainence Treatment of Opioid Dependence with Tramadol. J Neurosci Rural Pract 2019; 8:S98-S101. [PMID: 28936080 PMCID: PMC5602271 DOI: 10.4103/jnrp.jnrp_422_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Although tramadol has been used in the management of acute withdrawal in patients with opioid dependence, its use for maintenance treatment as a harm reduction approach has not been assessed systematically. This case series describes patients with opioid dependence who were treated with tramadol for long-term maintenance. Methods: Patients with opioid dependence who received treatment at the National Drug Dependence Treatment Centre of All India Institute of Medical Sciences, New Delhi, were included in the study. Patients who received at least 6 months of tramadol and had follow-up adherence of more than 80% were included in the case series. Results: A total of 25 cases were included, all of whom were males. The types of opioids being taken at the time of initiation of tramadol were natural opiates (poppy husk and raw opium), followed by heroin. The median dose of tramadol at initiation and maintenance was 300 mg/day. Nineteen patients were able to achieve complete abstinence to other opiates on tramadol. Conclusion: Tramadol may be an effective option in the long-term management of patients with opioid dependence. Further studies are required for establishing the efficacy of tramadol for agonist management of patients with opioid dependence.
Collapse
Affiliation(s)
- Siddharth Sarkar
- Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Mohit Varshney
- Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Vaibhav Patil
- Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lal
- Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
16
|
Fugelstad A, Thiblin I, Johansson LA, Ågren G, Sidorchuk A. Opioid-related deaths and previous care for drug use and pain relief in Sweden. Drug Alcohol Depend 2019; 201:253-259. [PMID: 31260826 DOI: 10.1016/j.drugalcdep.2019.04.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 04/12/2019] [Accepted: 04/16/2019] [Indexed: 11/27/2022]
Abstract
AIM In 2006-2014, the rate of drug-related deaths, typically opioid poisonings, more than doubled in Sweden. Opioid prescriptions for pain control or opioid agonist therapy also increased. In this retrospective study, we compared death rates between individuals whose first recorded contact with prescribed opioids was for pain control and individuals that had received substance use disorder (SUD) treatment before their first recorded opioid prescription. METHODS We included 2834 forensically examined individuals (ages 15-64 years) that died of poisoning in Sweden in 2006-2014. For each death we acquired data on previous opioid prescriptions and SUD treatments. We compared three study groups: pain control (n = 788); a SUD treatment group (n = 1629); and a group with no prescription for pain control or SUD treatment (n = 417). RESULTS Overall fatal poisonings increased from 2.77 to 7.79 (per 100,000 individuals) from 2006 to 2014 (relative 181% increase). Fatal poisoning increased from 2006 to 2014 by 269% in the pain control group (0.64 to 2.36 per 100,000) and by 238% in the SUD treatment group (1.35 to 4.57 per 100,000). Heroin-related deaths remained constant; consequently, the increase was likely attributable to prescription opioids. CONCLUSION A rapid increase in deaths attributable mainly to prescription opioids for pain control, was reported previously in the United States. Our study indicated that increased access to prescription opioids might contribute to higher death rates also in Sweden among patients seeking pain control and individuals with an established SUD; however, deaths related to prescription opioids mainly occurred among those with SUDs.
Collapse
Affiliation(s)
- Anna Fugelstad
- Department of Clinical Neuroscience, Karolinska Institute, Götgatan 83E, SE-11662 Stockholm, Sweden.
| | - Ingmar Thiblin
- Department of Surgical Sciences, Section for Forensic Medicine, Uppsala University, Box 1024, SE-75140 Uppsala, Sweden.
| | - Lars Age Johansson
- Department of Public Health and Caring Sciences, Section for Social Medicine, Uppsala University, Box 564, SE-75122, Uppsala, Sweden.
| | - Gunnar Ågren
- Former National Institute of Public Health, Götgatan 83E, SE-11662 Stockholm, Sweden.
| | - Anna Sidorchuk
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institute, and Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden.
| |
Collapse
|
17
|
Johnson B, Richert T. Non-prescribed use of methadone and buprenorphine prior to opioid substitution treatment: lifetime prevalence, motives, and drug sources among people with opioid dependence in five Swedish cities. Harm Reduct J 2019; 16:31. [PMID: 31046774 PMCID: PMC6498489 DOI: 10.1186/s12954-019-0301-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 04/15/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Opioid substitution treatment (OST) with methadone or buprenorphine is the most effective means of treating opioid dependence. If these substances are used by people who are not undergoing OST, they can however carry serious risks. This article examines the lifetime prevalence, motives, and drug sources for such use, as well as geographical differences in these variables. METHODS Structured interviews were conducted with 411 patients from 11 OST clinics in five Swedish cities. The researchers carried out 280 interviews on-site, while 131 interviews were conducted by specially trained patients through privileged access interviewing. Data were analyzed by frequency and average calculations, cross-tabulations, and χ2 tests. RESULTS The lifetime prevalence of non-prescribed use was 87.8% for methadone, 80.5% for buprenorphine, and 50.6% for buprenorphine/naloxone. Pseudo-therapeutic motives-avoiding withdrawal symptoms, staying clean from heroin, detoxification, or taking care of one's own OST-were commonly cited as driving the use, while using the drugs for euphoric purposes was a less common motive. Most respondents had bought or received the substances from patients in OST, but dealers were also a significant source of non-prescribed methadone and buprenorphine. Geographical differences of use, motives, and sources suggest that prescription practices in OST have a great impact on which substances are used outside of the treatment. CONCLUSIONS Experiences of non-prescribed use of methadone and buprenorphine are extremely common among those in OST in southern Sweden. As the use is typically driven by pseudo-therapeutic motives, increased access to OST might decrease the illicit demand for these substances. Buprenorphine/naloxone has a lower abuse potential than buprenorphine and should therefore be prioritized as the prescribed drug. Supervised dosage and other control measures are important provisions in the prevention of drug diversion and non-prescribed use among people not undergoing OST.
Collapse
Affiliation(s)
- Björn Johnson
- Department of Social Work, Malmö University, Malmö, Sweden
| | - Torkel Richert
- Department of Social Work, Malmö University, Malmö, Sweden
| |
Collapse
|
18
|
Gravensteen IK, Ekeberg Ø, Thiblin I, Helweg-Larsen K, Hem E, Rogde S, Tøllefsen IM. Psychoactive substances in natural and unnatural deaths in Norway and Sweden - a study on victims of suicide and accidents compared with natural deaths in psychiatric patients. BMC Psychiatry 2019; 19:33. [PMID: 30658618 PMCID: PMC6339417 DOI: 10.1186/s12888-019-2015-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 01/04/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The extent of post-mortem detection of specific psychoactive drugs may differ between countries, and may greatly influence the national death register's classification of manner and cause of death. The main objective of the present study was to analyse the magnitude and pattern of post-mortem detection of various psychoactive substances by the manner of death (suicide, accidental, undetermined and natural death with a psychiatric diagnosis) in Norway and Sweden. METHODS The Cause of Death Registers in Norway and Sweden provided data on 600 deaths in 2008 from each country, of which 200 were registered as suicides, 200 as accidents or undetermined manner of death and 200 as natural deaths in individuals with a diagnosis of mental disorder as the underlying cause of death. We examined death certificates and forensic reports including toxicological analyses. RESULTS The detection of psychoactive substances was commonly reported in suicides (66 and 74% in Norway and Sweden respectively), accidents (85 and 66%), undetermined manner of deaths (80% in the Swedish dataset) and in natural deaths with a psychiatric diagnosis (50 and 53%). Ethanol was the most commonly reported substance in the three manners of death, except from opioids being more common in accidental deaths in the Norwegian dataset. In cases of suicide by poisoning, benzodiazepines and z-drugs were the most common substances in both countries. Heroin or morphine was the most commonly reported substance in cases of accidental death by poisoning in the Norwegian dataset, while other opioids dominated the Swedish dataset. Anti-depressants were found in 22% of the suicide cases in the Norwegian dataset and in 29% of suicide cases in the Swedish dataset. CONCLUSIONS Psychoactive substances were detected in 66 and 74% of suicides and in 85 and 66% of accidental deaths in the Norwegian and Swedish datasets, respectively. Apart from a higher detection rate of heroin in deaths by accident in Norway than in Sweden, the pattern of detected psychoactive substances was similar in the two countries. Assessment of a suicidal motive may be hampered by the common use of psychoactive substances in suicide victims.
Collapse
Affiliation(s)
- Ida Kathrine Gravensteen
- 0000 0004 0389 8485grid.55325.34Department of Forensic Sciences, Oslo University Hospital, Box 4950 Nydalen, N-0424 Oslo, Norway
| | - Øivind Ekeberg
- 0000 0004 1936 8921grid.5510.1Department of Behavioural Sciences in Medicine, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Box 1111 Blindern, N-0317 Oslo, Norway ,0000 0004 0389 8485grid.55325.34Division of Mental Health and Addiction, Oslo University Hospital Ullevaal, Box 4956 Nydalen, N-0424 Oslo, Norway
| | - Ingemar Thiblin
- 0000 0004 1936 9457grid.8993.bDepartment of Surgical Sciences, Uppsala University, Box 256, 751 05 Uppsala, Sweden
| | - Karin Helweg-Larsen
- 0000 0001 0674 042Xgrid.5254.6Department of Social Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Erlend Hem
- 0000 0004 1936 8921grid.5510.1Department of Behavioural Sciences in Medicine, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Box 1111 Blindern, N-0317 Oslo, Norway ,0000 0004 0389 8485grid.55325.34Division of Mental Health and Addiction, Oslo University Hospital Ullevaal, Box 4956 Nydalen, N-0424 Oslo, Norway
| | - Sidsel Rogde
- 0000 0004 0389 8485grid.55325.34Department of Forensic Sciences, Oslo University Hospital, Box 4950 Nydalen, N-0424 Oslo, Norway ,0000 0004 1936 8921grid.5510.1Institute of Clinical Medicine, University of Oslo, Box 1072 Blindern, N- 0316 Oslo, Norway
| | - Ingvild Maria Tøllefsen
- Division of Medicine, Department of Acute Medicine, Oslo University Hospital Ullevaal, Box 4950 Nydalen, N-0424, Oslo, Norway.
| |
Collapse
|
19
|
Cicero TJ, Ellis MS, Chilcoat HD. Understanding the use of diverted buprenorphine. Drug Alcohol Depend 2018; 193:117-123. [PMID: 30359928 DOI: 10.1016/j.drugalcdep.2018.09.007] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 08/31/2018] [Accepted: 09/02/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Buprenorphine is approved in many countries for the treatment of opioid use disorder (OUD), but problems with diversion and abuse exist. There is a need to understand how and why patients use diverted buprenorphine, and whether barriers to access contribute to illicit use. METHODS Adults >18 years with DSM-IV criteria for substance use disorder and primarily using an opioid completed the online Survey of Key Informants' Patients (SKIP) between August and September 2016. The survey included closed- and open-ended questions regarding reasons for buprenorphine use with and without a prescription, sources of buprenorphine, route of administration, and barriers to treatment. RESULTS Of 303 respondents, 175 (58%) reported a history of diverted buprenorphine use, 65 (37%) of whom reported never receiving a prescription. The most common reasons for illicit buprenorphine use were consistent with therapeutic use: to prevent withdrawal (79%), maintain abstinence (67%), or self-wean off drugs (53%). Approximately one-half (52%) reported using buprenorphine to get high or alter mood, but few (4%) indicated that it was their drug of choice. Among respondents who had used diverted buprenorphine, 33% reported that they had issues finding a doctor or obtaining buprenorphine on their own. Most (81%) of these participants indicated they would prefer using prescribed buprenorphine, if available. CONCLUSIONS Although 58% of survey respondents reported a history of using diverted buprenorphine, the most frequently cited reasons for non-prescription use were consistent with therapeutic use. Diversion was partially driven by barriers to access, and an unmet need for OUD treatment persists.
Collapse
Affiliation(s)
- Theodore J Cicero
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States
| | - Matthew S Ellis
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States
| | - Howard D Chilcoat
- Indivior, Inc., Richmond, VA, United States; Department of Mental Health, Johns Hopkins Bloomberg School of Mental Health, Baltimore, MD, United States.
| |
Collapse
|
20
|
High buprenorphine-related mortality is persistent in Finland. Forensic Sci Int 2018; 291:76-82. [DOI: 10.1016/j.forsciint.2018.08.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/06/2018] [Accepted: 08/07/2018] [Indexed: 11/22/2022]
|
21
|
Ghosh A, Basu D, Avasthi A. Buprenorphine-based opioid substitution therapy in India: A few observations, thoughts, and opinions. Indian J Psychiatry 2018; 60:361-366. [PMID: 30405267 PMCID: PMC6201663 DOI: 10.4103/psychiatry.indianjpsychiatry_218_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The most evidence-based treatment for opioid dependence is opioid agonist maintenance treatment also known as opioid substitution therapy (OST). However, there are some critical, yet unaddressed issues of buprenorphine-based substitution therapy, especially in the Indian context. These comprise of generalizability of the evidence for OST, especially for natural and pharmaceutical opioids and for all age groups, optimum dose and duration of OST, and mode of treatment delivery including the frequency of dispensing. Notwithstanding the use of buprenorphine-naloxone combination, abuse and diversion are serious but often underreported problems. There is an urgent need for health services research in India on OST, focusing on these aspects. Rather than directly copying from Western models, it is important to try to understand the useful and safe program and policy options likely to be applicable in the Indian setting, with our own assets as well as vulnerabilities.
Collapse
Affiliation(s)
- Abhishek Ghosh
- Department of Psychiatry, Drug De-Addiction and Treatment Centre, PGIMER, Chandigarh, India
| | - Debasish Basu
- Department of Psychiatry, Drug De-Addiction and Treatment Centre, PGIMER, Chandigarh, India
| | - Ajit Avasthi
- Department of Psychiatry, PGIMER, Chandigarh, India
| |
Collapse
|
22
|
Majer JM, Beasley C, Stecker E, Bobak TJ, Norris J, Nguyen HM, Ogata M, Siegel J, Wiedbusch E, Dovale I, Gelfman N, Callahan S, Jason LA. Oxford House Residents' Attitudes Toward Medication Assisted Treatment Use in Fellow Residents. Community Ment Health J 2018; 54:571-577. [PMID: 29302767 DOI: 10.1007/s10597-017-0218-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 12/26/2017] [Indexed: 11/24/2022]
Abstract
Methadone and buprenorphine/naloxone are medication assisted treatment (MAT) options for treating opioid use disorder, yet attitudes regarding their use within abstinence-based recovery homes have not been assessed. The present investigation examined attitudes regarding MAT utilization among residents living in Oxford Houses. This cross-sectional investigation compared residents (n = 87) receiving MAT whose recent drug use involved opioids, and two groups not receiving MATs; those who had used opioids and those who had used substances other than opioids. The vast majority of residents were not receiving MAT, yet 32% reported MAT histories. Negative attitudes regarding MAT were observed among residents who were not receiving MAT. Those presently receiving MAT reported mixed attitudes regarding the use of methadone and buprenorphine/naloxone, and two of these residents reported they had never been prescribed MAT. Findings suggest that abstinence-based recovery homes such as Oxford Houses may not be optimal resources for persons receiving MATs.
Collapse
Affiliation(s)
- John M Majer
- Social Science Department, Harry S. Truman College, 1145 W. Wilson Ave., Chicago, IL, 60640, USA.
| | - Christopher Beasley
- Psychology Department, Washington College, 300 Washington Ave., Chestertown, MD, 21620, USA.,Department of Social, Behavioral, and Human Services, University of Washington, 1900 Commerce St., Tacoma, WA, 98402, USA
| | - Emily Stecker
- Psychology Department, Washington College, 300 Washington Ave., Chestertown, MD, 21620, USA
| | - Ted J Bobak
- Center for Community Research, DePaul University, 990 W. Fullerton Ave., Chicago, IL, USA
| | - Joshua Norris
- Center for Community Research, DePaul University, 990 W. Fullerton Ave., Chicago, IL, USA
| | - Hai Minh Nguyen
- Center for Community Research, DePaul University, 990 W. Fullerton Ave., Chicago, IL, USA
| | - Maisie Ogata
- Center for Community Research, DePaul University, 990 W. Fullerton Ave., Chicago, IL, USA
| | - Jordana Siegel
- Center for Community Research, DePaul University, 990 W. Fullerton Ave., Chicago, IL, USA
| | - Elzbieta Wiedbusch
- Center for Community Research, DePaul University, 990 W. Fullerton Ave., Chicago, IL, USA
| | | | | | | | - Leonard A Jason
- Center for Community Research, DePaul University, 990 W. Fullerton Ave., Chicago, IL, USA
| |
Collapse
|
23
|
Hulme S, Bright D, Nielsen S. The source and diversion of pharmaceutical drugs for non-medical use: A systematic review and meta-analysis. Drug Alcohol Depend 2018; 186:242-256. [PMID: 29626777 DOI: 10.1016/j.drugalcdep.2018.02.010] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 02/18/2018] [Accepted: 02/20/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND The non-medical use (NMU) of pharmaceutical drugs is an increasing public health concern. This systematic review consolidates current knowledge about how pharmaceutical drugs are obtained for NMU and the processes and people involved in diversion. METHODS Peer-reviewed and grey literature databases were searched for empirical studies published between 1996 and 2017 that examined the source or diversion of pharmaceutical opioids, sedatives or stimulants for NMU in countries with reported misuse problems. Pooled prevalence meta-analyses using random effects models were used to estimate the prevalence of medical and non-medical sourcing reported by end-users, and gifting, selling and trading by various populations. RESULTS This review synthesizes the findings of 54 cross-sectional studies via meta-analyses, with a remaining 95 studies examined through narrative review. Pharmaceutical drugs are primarily sourced for NMU from friends and family (57%, 95% CI 53%-62%, I2 = 98.5, n = 30) and despite perceptions of healthcare professionals to the contrary, illegitimate practices such as doctor shopping are uncommon (7%, 95% CI 6%-10%, I2 = 97.4, n = 29). Those at risk of diversion include patients displaying aberrant medication behaviors, people with substance use issues and students in fraternity/sorority environments. Sourcing via dealers is also common (32%, 95% CI 23%-41%, I2 = 99.8, n = 25) and particularly so among people who use illicit drugs (47%, 95% CI 35%-60%, I2 = 99.1, n = 15). There is little to no organized criminal involvement in the pharmaceutical black market. CONCLUSION Pharmaceutical drugs for NMU are primarily sourced by end-users through social networks. Future research should examine how dealers source pharmaceutical drugs.
Collapse
Affiliation(s)
- Shann Hulme
- National Drug and Alcohol Research Centre, 22-32 King St, Randwick, NSW, 2031, Australia.
| | - David Bright
- School of Social Sciences, UNSW Australia, High Street, Kensington, NSW, 2052, Australia
| | - Suzanne Nielsen
- National Drug and Alcohol Research Centre, 22-32 King St, Randwick, NSW, 2031, Australia
| |
Collapse
|
24
|
Reddon H, Ho J, DeBeck K, Milloy MJ, Liu Y, Dong H, Ahamad K, Wood E, Kerr T, Hayashi K. Increasing diversion of methadone in Vancouver, Canada, 2005-2015. J Subst Abuse Treat 2018; 85:10-16. [PMID: 29291766 PMCID: PMC5753607 DOI: 10.1016/j.jsat.2017.11.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 11/02/2017] [Accepted: 11/27/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM Although methadone, an opioid agonist, has been an effective medication used to treat opioid use disorder for over 40years, recent studies have found that methadone was identified in more than a quarter of prescription opioid-related deaths among people who use illicit drugs in Vancouver, Canada. Thus, we sought to longitudinally examine the availability of diverted methadone among people who inject drugs (PWID). DESIGN AND METHODS Data were collected from three prospective cohorts of PWID in Vancouver, Canada between December 2005 and May 2015. Multivariable generalized estimating equation logistic regression was used to identify temporal trends in the immediate availability of diverted methadone (defined as the ability to acquire illicit methadone in <10min). RESULTS A total of 2092 participants, including 727 (34.8%) women, were included in the present study. In the multivariable analyses after adjusting for a range of potential confounders, later calendar year (adjusted odds ratio [AOR]=1.21 per year; 95% confidence interval [CI]: 1.19-1.23) was independently and positively associated with reporting immediate availability of diverted methadone. CONCLUSIONS We observed a significant increase in the reported availability of diverted methadone among PWID over a ten-year follow-up period. Further research is needed to identify strategies to limit methadone diversion and assess the impact of alternative medications that are equally effective but safer, such as buprenorphine/naloxone.
Collapse
Affiliation(s)
- Hudson Reddon
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main St W, Hamilton, ON L8N 3Z5, Canada
| | - Joel Ho
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, GC425-820 Sherbrook Street, Winnipeg, MB R3T 2N2, Canada
| | - Kora DeBeck
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; School of Public Policy, Simon Fraser University, 515 W Hastings St, Vancouver, BC V6B 5K3, Canada
| | - M-J Milloy
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Yang Liu
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Huiru Dong
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC V6T 1Z3 E Mall, Vancouver, BC V6T 1Z3, Canada
| | - Keith Ahamad
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Family Practice, University of British Columbia, St. Paul's Hospital, Department of Family and Community Medicine, 1081 Burrard St., Vancouver, BC V6Z 1Y6, Canada
| | - Evan Wood
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Faculty of Health Sciences, Simon Fraser University, Blusson Hall, 8888 University Drive, Burnaby, BC V5A 1S6, Canada.
| |
Collapse
|
25
|
Abstract
Opioid use disorders (OUDs) have long been a global problem, but the prevalence rates have increased over 20 years to epidemic proportions in the US, with concomitant increases in morbidity and all-cause mortality, but especially opioid overdose. These increases are in part attributable to a several-fold expansion in the prescription of opioid pain medications over the same time period. Opioid detoxification and psychosocial treatments alone have each not yielded sufficient efficacy for OUD, but μ-opioid receptor agonist, partial agonist, and antagonist medications have demonstrated the greatest overall benefit in OUD treatment. Buprenorphine, a μ-opioid receptor partial agonist, has been used successfully on an international basis for several decades in sublingual tablet and film preparations for the treatment of OUD, but the nature of formulation, which is typically self-administered, renders it susceptible to nonadherence, diversion, and accidental exposure. This article reviews the clinical trial data for novel buprenorphine delivery systems in the form of subcutaneous depot injections, transdermal patches, and subdermal implants for the treatment of OUD and discusses both the clinical efficacy of longer-acting formulations through increasing consistent medication exposure and their potential utility in reducing diversion. These new delivery systems also offer new dosing opportunities for buprenorphine and strategies for dosing intervals in the treatment of OUD.
Collapse
Affiliation(s)
- Richard N Rosenthal
- Department of Psychiatry, Addiction Institute at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York
| | - Viral V Goradia
- Department of Psychiatry, Upstate Medical University, Syracuse, NY, USA
| |
Collapse
|
26
|
Kenney SR, Anderson BJ, Bailey GL, Stein MD. The relationship between diversion-related attitudes and sharing and selling buprenorphine. J Subst Abuse Treat 2017; 78:43-47. [PMID: 28554602 PMCID: PMC7189524 DOI: 10.1016/j.jsat.2017.04.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 04/25/2017] [Accepted: 04/26/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Buprenorphine medication-assisted treatment (B-MAT) is an efficacious and popular outpatient treatment for opioid use disorder. However, the likelihood of buprenorphine diversion is a public health concern. We examined the relationship between attitudes toward diversion as predictors of both sharing and selling buprenorphine. METHOD Participants (n=476) were patients undergoing short-term inpatient opioid detoxification. Multinomial logistic regression was used to estimate the adjusted association of sharing and selling buprenorphine with demographics, substance use behaviors, and attitudes toward sharing and selling buprenorphine. RESULTS Among the two hundred persons who had ever been prescribed buprenorphine (73.4% male, 89% heroin users), 50.5% reported they had shared buprenorphine and 28.0% reported they had sold buprenorphine. Controlling for other covariates, the odds of sharing buprenorphine were 3.17 (95% CI 1.21; 8.32) times higher for persons who agreed that it was "right to share buprenorphine with dope sick friends" than for those who did not agree with this attitude. Attitudes toward selling (OR 2.92; 95% CI 1.35; 6.21) and sharing (OR 4.12; 95% CI 1.64; 10.32) buprenorphine were the only significant correlates of selling, with the odds of selling exponentially greater among persons with favorable attitudes toward sharing or selling buprenorphine. CONCLUSIONS Although considered diversion, sharing B-MAT is normative among B-MAT patients. Assessing B-MAT patients' attitudes about diversion may help identify patients requiring enhanced oversight, education, or intervention aimed at modifying attitudes to reduce their likelihood to share or sell buprenorphine.
Collapse
Affiliation(s)
- Shannon R Kenney
- Behavioral Medicine Department, Butler Hospital, Providence, RI 02906, United States; Warren Alpert Medical School of Brown University, Providence, RI 02912, United States.
| | - Bradley J Anderson
- Behavioral Medicine Department, Butler Hospital, Providence, RI 02906, United States
| | - Genie L Bailey
- Warren Alpert Medical School of Brown University, Providence, RI 02912, United States; Stanley Street Treatment and Resources, Inc., Fall River, MA 02720, United States
| | - Michael D Stein
- Behavioral Medicine Department, Butler Hospital, Providence, RI 02906, United States; Boston University School of Public Health, Boston, MA 02118, United States
| |
Collapse
|
27
|
Ledberg A. Mortality related to methadone maintenance treatment in Stockholm, Sweden, during 2006–2013. J Subst Abuse Treat 2017; 74:35-41. [DOI: 10.1016/j.jsat.2016.12.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 12/06/2016] [Accepted: 12/16/2016] [Indexed: 01/18/2023]
|
28
|
Abstract
This paper is the thirty-eighth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2015 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.
Collapse
Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
| |
Collapse
|
29
|
Jungen H, Andresen-Streichert H, Müller A, Iwersen-Bergmann S. Monitoring Intravenous Abuse of Methadone or Buprenorphine in Opiate Maintenance Treatment (OMT): A Simple and Fast LC–MS-MS Method for the Detection of Disaccharides in Urine Samples. J Anal Toxicol 2016; 41:22-31. [DOI: 10.1093/jat/bkw099] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 06/10/2016] [Accepted: 07/03/2016] [Indexed: 11/12/2022] Open
|
30
|
Non-Prescribed Buprenorphine in New York City: Motivations for Use, Practices of Diversion, and Experiences of Stigma. J Subst Abuse Treat 2016; 70:81-86. [PMID: 27692193 DOI: 10.1016/j.jsat.2016.08.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 07/28/2016] [Accepted: 08/05/2016] [Indexed: 10/21/2022]
Abstract
Non-medical use of opioid analgesics (OAs) has increased in the United States over the past decade. Concurrently, access to opioid agonist therapies (OATs) such as buprenorphine has expanded. However, there has been little in-depth qualitative exploration into circumstances surrounding buprenorphine diversion and non-prescribed use. This study reports on qualitative data from in-depth interviews conducted with persons in New York City reporting non-medical OA use in the past 12 months. Participants (n=42) were aged between 18 and 49 years. The majority were male (n=29) and non-Hispanic White (n=35). All participants self-reported physical opioid dependence. Motivations for non-prescribed buprenorphine use included the abatement of withdrawal symptoms or a self-initiated detoxification or treatment plan. Few participants reported buprenorphine use for euphoric effect, and no participants reported using buprenorphine as a primary drug. Buprenorphine diversion primarily occurred as a means of supporting ongoing illicit drug use, and no participants reported selling buprenorphine as a primary source of income. Participants reported misinformation around some key areas of buprenorphine induction and use, as well as stigma within peer networks and from drug treatment providers. As access to buprenorphine treatment continues to expand in the United States, enhancing patient education is a critical step toward minimizing diversion and incidental harms from non-prescribed use.
Collapse
|
31
|
Affiliation(s)
- Marc A Schuckit
- From the Department of Psychiatry, University of California, San Diego, La Jolla
| |
Collapse
|
32
|
Kimergård A, Deluca P, Hindersson P, Breindahl T. How Resistant to Tampering are Codeine Containing Analgesics on the Market? Assessing the Potential for Opioid Extraction. Pain Ther 2016; 5:187-201. [PMID: 27295264 PMCID: PMC5130903 DOI: 10.1007/s40122-016-0053-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Indexed: 01/08/2023] Open
Abstract
Introduction Misuse of opioid analgesics, in combination with diversion, dependence, and fatal overdoses, presents a serious problem for public health, which affects many countries worldwide. Within this context, tampering with opioids has been associated with serious harm. The aim of the present study was to assess the tampering potential of codeine combination analgesics on the market (containing codeine/non-opioid analgesics) by the extraction of codeine. Methods Codeine was extracted from three combination formulations sold lawfully from licensed pharmacies without a medical prescription in Denmark and the UK. Extraction of codeine followed tampering procedures available on the Internet. The amounts of codeine and accompanying non-opioid analgesics in tampering products were analysed with liquid chromatography and tandem mass spectrometry (LC–MS/MS). Results LC–MS/MS showed recoveries of the total amounts of codeine in tampering products of 81–84% from Product 1 (codeine/acetylsalicylic acid); 61–67% from Product 2 (codeine/ibuprofen); and 42–71% from Product 3 (codeine/paracetamol). Recoveries of non-opioid analgesics ranged between: 57–73% acetylsalicylic acid; 5.5–8.5% ibuprofen, and 5.0–9.2% paracetamol. Conclusion With the tampering procedures used, high amounts of codeine were separated from the accompanying analgesics in some, but not in all of the codeine containing formulations. Evidence-based medicine regulation, treatment for opioid dependence, and information to minimise risks to the public are essential components of an effective public health strategy to address the harms of tampering and misuse. Funding Marie Pedersen and Jensine Heiberg Foundation.
Collapse
Affiliation(s)
- Andreas Kimergård
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Addiction Sciences Building, 4 Windsor Walk, London, SE5 8BB, UK.
| | - Paolo Deluca
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Addiction Sciences Building, 4 Windsor Walk, London, SE5 8BB, UK
| | - Peter Hindersson
- Department of Clinical Biochemistry, North Denmark Regional Hospital (Aalborg University), Hjørring, Denmark
| | - Torben Breindahl
- Department of Clinical Biochemistry, North Denmark Regional Hospital (Aalborg University), Hjørring, Denmark
| |
Collapse
|
33
|
Diversion of methadone and buprenorphine from opioid substitution treatment: the importance of patients' attitudes and norms. J Subst Abuse Treat 2015; 54:50-5. [PMID: 25744650 DOI: 10.1016/j.jsat.2015.01.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 01/23/2015] [Accepted: 01/28/2015] [Indexed: 11/23/2022]
Abstract
AIMS Methadone and buprenorphine diversion by patients in opioid substitution treatment (OST) is a poorly understood phenomenon. We study the norms and attitudes on diversion among OST patients, including the role these norms and attitudes play as diversion risk factors. We also study whether perceived quality of care, social bonds to treatment staff, and deterrence can be associated with diversion. METHODS Structured interviews were conducted with 411 patients from eleven OST programs. In total, 280 interviews were done on site by the researchers, while 131 interviews were conducted through peer interviewing by specially trained patients. The data was analyzed through frequency- and averages-calculations, cross-tabulations, and logistic regression analysis. RESULTS Most patients consider diversion as mostly positive (83.7%), morally right (76.8%), and without any significant risk of detection (66.9%). Individual differences in norms and risk perceptions may play a role in explaining variations in diversion; patients who consider it right to share medication with friends report higher treatment-episode diversion than other patients (OR 1.455, p = 0.016). Patients who perceive control measures as effective report lower diversion than other patients (OR = 0.655, p = 0.013). Furthermore, data indicate that patients who are satisfied with the care and service are less prone to engage in diversion. Social bonds with treatment staff seem to be less importance. CONCLUSIONS The norm system described by patients resemble Bourgois' 'moral economy of sharing' concept-not sharing drugs with friends in withdrawal is considered unethical. Efforts to decrease diversion may focus on lifestyle-changing interventions, and reducing black market demand for illicit medications by expanding access to treatment.
Collapse
|
34
|
Richert T, Johnson B. Long-term self-treatment with methadone or buprenorphine as a response to barriers to opioid substitution treatment: the case of Sweden. Harm Reduct J 2015; 12:1. [PMID: 25889208 PMCID: PMC4337060 DOI: 10.1186/s12954-015-0037-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 01/20/2015] [Indexed: 11/11/2022] Open
Abstract
Background It is well known that illicit use of methadone and buprenorphine is common among people with an opioid dependence. Less notice has been taken of the fact that these substances are also used for extended periods of self-treatment, as a way of handling barriers to OST. In this study, motives for self-treatment are investigated, as well as attitudes and perceived barriers to OST among drug users with an opioid dependence in Sweden. Method The study is based on qualitative research interviews with 27 opioid users who have treated themselves with methadone or buprenorphine for a period of at least three months. Results The duration of self-treatment among the interviewees varied from 5 months to 7 years. Self-treatment often began as a result of a wish to change their life situation or to cut back on heroin, in conjunction with perceived barriers to OST. These barriers consisted of (1) difficulties in gaining access to OST due to strict inclusion criteria, limited access to treatment or a bureaucratic and arduous assessment process, (2) difficulties remaining in treatment, and (3) ambivalence toward or reluctance to seek OST, primarily due to a fear of stigmatization or disciplinary action. Self-treatment was described as an attractive alternative to OST, as a stepping stone to OST, and as a way of handling waiting lists, or as a saving resource in case of involuntary discharge. Conclusion Illicit use of methadone and buprenorphine involve risks but may also have important roles to play for users who are unwilling or not given the opportunity to enter OST. A restrictive and strict rehabilitation-oriented treatment model may force many to manage their own treatment. More generous inclusion criteria, a less complex admission process, fewer involuntary discharges, and less paternalistic treatment may lead to increasing numbers seeking OST. Control measures are necessary to prevent diversion and harmful drug use but must be designed in such a way that they impose as few restrictions as possible on the daily life of patients.
Collapse
Affiliation(s)
- Torkel Richert
- Department of Social Work, Malmö University, Malmo, Sweden.
| | - Björn Johnson
- Department of Social Work, Malmö University, Malmo, Sweden.
| |
Collapse
|