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Walley AY, Lodi S, Li Y, Bernson D, Babakhanlou-Chase H, Land T, Larochelle MR. Association between mortality rates and medication and residential treatment after in-patient medically managed opioid withdrawal: a cohort analysis. Addiction 2020; 115:1496-1508. [PMID: 32096908 PMCID: PMC7854020 DOI: 10.1111/add.14964] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 09/16/2019] [Accepted: 01/06/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Medically managed opioid withdrawal (detox) can increase the risk of subsequent opioid overdose. We assessed the association between mortality following detox and receipt of medications for opioid use disorder (MOUD) and residential treatment after detox. DESIGN Cohort study generated from individually linked public health data sets. SETTING Massachusetts, USA. PARTICIPANTS A total of 30 681 opioid detox patients with 61 819 detox episodes between 2012 and 2014. MEASUREMENTS Treatment categories included no post-detox treatment, MOUD, residential treatment or both MOUD and residential treatment identified at monthly intervals. We classified treatment exposures in two ways: (a) 'on-treatment' included any month where a treatment was received and (b) 'with-discontinuation' individuals were considered exposed through the month following treatment discontinuation. We conducted multivariable Cox proportional hazards analyses and extended Kaplan-Meier estimator cumulative incidence for all-cause and opioid-related mortality for the treatment categories as monthly time-varying exposure variables. FINDINGS Twelve months after detox, 41% received MOUD for a median of 3 months, 35% received residential treatment for a median of 2 months and 13% received both for a median of 5 months. In on-treatment analyses for all-cause mortality compared with no treatment, adjusted hazard ratios (AHR) were 0.34 [95% confidence interval (CI) = 0.27-0.43] for MOUD, 0.63 (95% CI = 0.47-0.84) for residential treatment and 0.11 (95% CI = 0.03-0.43) for both. In with-discontinuation analyses for all-cause mortality, compared with no treatment, AHRs were 0.52 (95% CI = 0.42-0.63) for MOUD, 0.76 (95% CI = 0.59-0.96) for residential treatment and 0.21 (95% CI = 0.08-0.55) for both. Results were similar for opioid-related overdose mortality. CONCLUSIONS Among people who have undergone medically managed opioid withdrawal, receipt of medications for opioid use disorder, residential treatment or the combination of medications for opioid use disorder and residential treatment were associated with substantially reduced mortality compared with no treatment.
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Affiliation(s)
- Alexander Y. Walley
- Boston University School of Medicine-Boston Medical Center, 801 Massachusetts Avenue, Boston, MA 02118,Massachusetts Department of Public Health, 250 Washington Street, Boston, MA 02108
| | - Sara Lodi
- Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118
| | - Yijing Li
- Boston University School of Medicine-Boston Medical Center, 801 Massachusetts Avenue, Boston, MA 02118
| | - Dana Bernson
- Massachusetts Department of Public Health, 250 Washington Street, Boston, MA 02108
| | | | - Thomas Land
- University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA 01655
| | - Marc R. Larochelle
- Boston University School of Medicine-Boston Medical Center, 801 Massachusetts Avenue, Boston, MA 02118
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Morgan JR, Wang J, Barocas JA, Jaeger JL, Durham NN, Babakhanlou-Chase H, Bharel M, Walley AY, Linas BP. Opioid overdose and inpatient care for substance use disorder care in Massachusetts. J Subst Abuse Treat 2020; 112:42-48. [PMID: 32199545 PMCID: PMC7928069 DOI: 10.1016/j.jsat.2020.01.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Inpatient treatment for substance use disorders is a collection of strategies ranging from short term detoxification to longer term residential treatment. How those with opioid use disorder (OUD) navigate this inpatient treatment system after an encounter for detoxification and subsequent risk of opioid-related overdose is not well understood. METHODS We used a comprehensive Massachusetts database to characterize the movement of people with OUD through inpatient care from 2013 to 2015, identifying admissions to inpatient detoxification, subsequent inpatient care, and opioid overdose while navigating treatment. We measured the person-years accumulated during each transition period to calculate rates of opioid-related overdose, and investigated how overdose differed in select populations. RESULTS Sixty-one percent of inpatient detoxification admissions resulted in a subsequent inpatient detoxification admission without progressing to further inpatient care. Overall, there were 287 fatal and 7337 non-fatal overdoses. Persons exiting treatment after detoxification had the greatest risk of overdose (17.3 per 100 person-years) compared to those who exited after subsequent inpatient care (ranging from 5.9 to 6.6 overdoses per 100 person-years). Non-Hispanic whites were most at risk for opioid related overdose with 16 overdoses per 100 person-years and non-Hispanic blacks had the lowest risk with 5 overdoses per 100 person-years. CONCLUSIONS The majority of inpatient detoxification admissions do not progress to further inpatient care. Recurrent inpatient detoxification admission is common, likely signifying relapse. Rather than functioning as the first step to inpatient care, inpatient detoxification might be more effective as a venue for implementing strategies to expand addiction services or treatment such as medications for opioid use disorder.
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Affiliation(s)
- Jake R Morgan
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA.
| | - Jianing Wang
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Boston, MA, USA
| | - Joshua A Barocas
- Massachusetts General Hospital, Division of Infectious Diseases, Boston, MA, USA; Brigham and Women's Hospital, Division of Infectious Diseases, Boston, MA, USA
| | | | | | | | - Monica Bharel
- Massachusettes Department of Public Health, Boston, MA, USA
| | - Alexander Y Walley
- Massachusettes Department of Public Health, Boston, MA, USA; Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Benjamin P Linas
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Boston, MA, USA; Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
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A strengths-based case management intervention to link HIV-positive people who inject drugs in Russia to HIV care. AIDS 2019; 33:1467-1476. [PMID: 30964750 PMCID: PMC6635053 DOI: 10.1097/qad.0000000000002230] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Objective: To determine whether the Linking Infectious and Narcology Care strengths-based case management intervention was more effective than usual care for linking people who inject drugs (PWID) to HIV care and improving HIV outcomes. Design: Two-armed randomized controlled trial. Setting: Participants recruited from a narcology hospital in St. Petersburg, Russia. Participants: A total of 349 HIV-positive PWID not on antiretroviral therapy (ART). Intervention: Strengths-based case management over 6 months. Main outcome measures: Primary outcomes were linkage to HIV care and improved CD4+ cell count. We performed adjusted logistic and linear regression analyses controlling for past HIV care using the intention-to-treat approach. Results: Participants (N = 349) had the following baseline characteristics: 73% male, 12% any past ART use, and median values of 34.0 years of age and CD4+ cell count 311 cells/μl. Within 6 months of enrollment 51% of the intervention group and 31% of controls linked to HIV care (adjusted odds ratio 2.34; 95% confidence interval: 1.49–3.67; P < 0.001). Mean CD4+ cell count at 12 months was 343 and 354 cells/μl in the intervention and control groups, respectively (adjusted ratio of means 1.14; 95% confidence interval: 0.91, 1.42, P = 0.25). Conclusion: The Linking Infectious and Narcology Care strengths-based case management intervention was more effective than usual care in linking Russian PWID to HIV care, but did not improve CD4+ cell count, likely due to low overall ART initiation. Although case management can improve linkage to HIV care, specific approaches to initiate and adhere to ART are needed to improve clinical outcomes (e.g., increased CD4+ cell count) in this population.
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Goldman-Hasbun J, Nosova E, Kerr T, Wood E, DeBeck K. Homelessness and incarceration associated with relapse into stimulant and opioid use among youth who are street-involved in Vancouver, Canada. Drug Alcohol Rev 2019; 38:428-434. [PMID: 30896070 DOI: 10.1111/dar.12921] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 02/18/2019] [Accepted: 02/18/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND AIMS While much research has sought to identify the factors associated with initiation and cessation of various forms of drug use among vulnerable youth, little is known about relapse into drug use in this population. We sought to characterise relapse into stimulant and opioid use among street-involved youth in Vancouver, Canada. DESIGN AND METHODS Data were collected between 2005 and 2017 from the At-Risk Youth Study, a prospective cohort study of street-involved youth who use illicit drugs in Vancouver. Multivariable extended Cox regression was utilised to identify factors associated with relapse into illegal stimulants and/or opioids among youth who had previously ceased using stimulants and/or opioids for 6 months or longer. RESULTS Among 246 participants who reported a period of cessation lasting 6 months or longer, 165 (67.1%) relapsed at some point during study follow-up. Youth who were recently incarcerated (adjusted hazard ratio [AHR]: 1.46), homeless (AHR: 1.43), or had a history of daily stimulant use (AHR: 1.48) were significantly more likely to report relapse, while youth of who identified as white (AHR: 0.74) were significantly less likely to report relapse (all P < 0.05). DISCUSSION AND CONCLUSIONS Relapse into stimulants and/or opioids was common among youth in our setting, and incarceration, homelessness, and daily stimulant use were found to be positively associated with relapse among youth. Findings suggest that increased access to youth housing supports and alternatives to the criminalisation of drug use may help to reduce the rates of relapse into stimulants and/or opioids in this population.
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Affiliation(s)
| | | | - Thomas Kerr
- B.C. Centre on Substance Use, Vancouver, Canada.,Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Evan Wood
- B.C. Centre on Substance Use, Vancouver, Canada.,Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Kora DeBeck
- B.C. Centre on Substance Use, Vancouver, Canada.,School of Public Policy, Simon Fraser University, Vancouver, Canada
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McCann TV, Savic M, Ferguson N, Cheetham A, Witt K, Emond K, Bosley E, Smith K, Roberts L, Lubman DI. Recognition of, and attitudes towards, people with depression and psychosis with/without alcohol and other drug problems: results from a national survey of Australian paramedics. BMJ Open 2018; 8:e023860. [PMID: 30514822 PMCID: PMC6286471 DOI: 10.1136/bmjopen-2018-023860] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Continuing stigma towards mental health problems means that many individuals-especially men-will first present in crisis, with emergency services often the first point of call. Given this situation, the aims of this paper were to assess paramedics' ability to recognise, and their attitudes towards, males with clinically defined depression and psychosis with and without comorbid alcohol and other drug (AOD) problems. METHODS A cross-sectional national online survey of 1230 paramedics throughout Australia. The survey was based on four vignettes: depression with suicidal thoughts, depression with suicidal thoughts and comorbid alcohol problems, and psychosis with and without comorbid AOD problems. RESULTS Just under half of respondents recognised depression, but this decreased markedly to one-fifth when comorbid AOD problems were added to the vignette. In contrast, almost 90% recognised psychosis, but this decreased to just under 60% when comorbid AOD problems were added. Respondents were more likely to hold stigmatising attitudes towards people in the vignettes with depression and psychosis when comorbid AOD problems were present. Respondents endorsed questionnaire items assessing perceived social stigma more strongly than personal stigma. Desire for social distance was greater in vignettes focusing on psychosis with and without comorbid AOD problems than depression with and without comorbid AOD problems. CONCLUSIONS Paramedics need a well-crafted multicomponent response which involves cultural change within their organisations and more education to improve their recognition of, and attitudes towards, clients with mental health and AOD problems. Education should focus on the recognition and care of people with specific mental disorders rather than on mental disorders in general. It is essential that education also focuses on understanding and caring for people with AOD problems. Educational interventions should focus on aligning beliefs about public perceptions with personal beliefs about people with mental disorders and AOD problems.
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Affiliation(s)
- Terence V McCann
- Department of Nursing and Midwifery, Institute of Health and Sport, Victoria University, Melbourne, Victoria, Australia
| | - Michael Savic
- Turning Point, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Nyssa Ferguson
- Turning Point, Eastern Health, Melbourne, Victoria, Australia
| | - Alison Cheetham
- Turning Point, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Katrina Witt
- Turning Point, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Kate Emond
- Department of Rural Nursing and Midwifery, College of Health, Science and Engineering, La Trobe University, Bendigo, Victoria, Australia
| | - Emma Bosley
- Queensland Ambulance Service, Brisbane, Victoria, Australia
| | - Karen Smith
- Ambulance Victoria, Melbourne, Victoria, Australia
| | - Louise Roberts
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Dan I Lubman
- Turning Point, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
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Patterns of Non-injection Drug Use Associated with Injection Cessation among Street-Involved Youth in Vancouver, Canada. J Urban Health 2018; 95:267-277. [PMID: 29423896 PMCID: PMC5906385 DOI: 10.1007/s11524-017-0225-3] [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: 10/18/2022]
Abstract
Although abstinence from drug use is often a key goal of youth substance use treatment, transitioning to less harmful routes and types of drug use is desirable from both a clinical and public health perspective. Despite this, little is known about the trajectories of youth who inject drugs including changes in patterns of non-injection drug use. The At-Risk Youth Study (ARYS) is a longitudinal cohort of street-involved youth who use drugs in Vancouver, Canada. We used linear growth curve modeling to compare changes in non-injection drug use among participants who ceased injecting drugs for at least one 6-month period between September 2005 and May 2015 to matched controls who continued injecting over the same period. Of 387 eligible participants, 173 (44.7%) reported ceasing drug injection at least once. Non-injection drug use occurred during 160 (79.6%) periods of injection cessation. In adjusted linear growth curve analyses, the only non-injection drug use pattern observed to decrease significantly more than controls following injection cessation was daily crack/cocaine use (p = 0.024). With the exception of frequent crack/cocaine use, transitions out of injection drug use did not appear to coincide with increased reductions in patterns of non-injection drug use. Our findings indicate that most (80%) of the observed injection cessation events occurred in the context of ongoing substance use. Given that transitioning out of drug injection represents a significant reduction in risk and harm, efforts supporting vulnerable youth to move away from injecting may benefit from approaches that allow for ongoing non-injection drug use.
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