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Brezan F, Meyer M, Vogel M, Heimer J, Falcato L, Montagna J, Bruggmann P. Prolonged diacetylmorphine take-home during the COVID-19 pandemic-Results of a retrospective cohort study. Addiction 2024; 119:1421-1429. [PMID: 38644677 DOI: 10.1111/add.16503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 03/18/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND AND AIMS Legal regulations for dispensing in Swiss heroin-assisted treatment were relaxed during the COVID-19 pandemic, allowing prolonged take-home of up to 7 days instead of two to reduce patient contact and the risk of infection. Our study aimed to measure the consequences of this new practice. DESIGN, SETTING AND PARTICIPANTS This was a retrospective cohort study set in Switzerland's largest outpatient centre for opioid agonist therapy. One hundred and thirty-four (72.4%) of the 185 patients receiving oral diacetylmorphine (DAM) participated in the study. MEASUREMENTS Through the utilization of electronic medication prescription and dispensing software, as well as the electronic medical record, the following data were extracted to explore the potential consequences: dose of DAM, the number of antibiotic therapies, emergency hospitalizations and incarcerations. Age, gender, prescriptions for psychotrophic drugs and additional prescription for injectable DAM were tested to assess an increased risk of losing prolonged take-home privileges. Data in the year since prolonged take-home (period 2) were compared with data from the equivalent prior year (period 1). FINDINGS DAM take-home was not associated with a change in DAM dose (P = 0.548), the number of emergency hospitalizations (P = 0.186) or the number of incarcerations (P = 0.215); 79.1% of all patients were able to maintain their extended take-home privileges. However, patients who had injectable DAM experienced significant reductions in their prolonged take-home privileges. CONCLUSION Allowing patients to take home oral diacetylmorphine for up to 7 days as treatment for opioid use disorder does not appear to pose any demonstrable health risk. It is generally manageable for the large majority of patients. However, careful consideration of prolonged take-home for patients with additional injectable diacetylmorphine is recommended, as these patients are more likely to lose take-home privileges.
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Affiliation(s)
| | - Maximilian Meyer
- Psychiatric University Clinics Basel, University of Basel, Basel, Switzerland
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Marc Vogel
- Psychiatric University Clinics Basel, University of Basel, Basel, Switzerland
| | - Jakob Heimer
- Department of Mathematics, Seminar for Statistics, ETH Zurich, Zurich, Switzerland
| | - Luis Falcato
- Arud Centre for Addiction Medicine, Zurich, Switzerland
| | | | - Philip Bruggmann
- Arud Centre for Addiction Medicine, Zurich, Switzerland
- Institute of Primary Care, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Kolla G, Pauly B, Cameron F, Hobbs H, Ranger C, McCall J, Majalahti J, Toombs K, LeMaistre J, Selfridge M, Urbanoski K. "If it wasn't for them, I don't think I would be here": experiences of the first year of a safer supply program during the dual public health emergencies of COVID-19 and the drug toxicity crisis. Harm Reduct J 2024; 21:111. [PMID: 38849866 PMCID: PMC11157725 DOI: 10.1186/s12954-024-01029-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 05/29/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND In response to the devastating drug toxicity crisis in Canada driven by an unregulated opioid supply predominantly composed of fentanyl and analogues, safer supply programs have been introduced. These programs provide people using street-acquired opioids with prescribed, pharmaceutical opioids. We use six core components of safer supply programs identified by people who use drugs to explore participant perspectives on the first year of operations of a safer supply program in Victoria, BC, during the dual public health emergencies of COVID-19 and the drug toxicity crisis to examine whether the program met drug-user defined elements of an effective safer supply model. METHODS This study used a community-based participatory research approach to ensure that the research was reflective of community concerns and priorities, rather than being extractive. We interviewed 16 safer supply program participants between December 2020 and June 2021. Analysis was structured using the six core components of effective safer supply from the perspective of people who use drugs, generated through a prior study. RESULTS Ensuring access to the 'right dose and right drugs' of medications was crucial, with many participants reporting success with the available pharmaceutical options. However, others highlighted issues with the strength of the available medications and the lack of options for smokeable medications. Accessing the safer supply program allowed participants to reduce their use of drugs from unregulated markets and manage withdrawal, pain and cravings. On components related to program operations, participants reported receiving compassionate care, and that accessing the safer supply program was a non-stigmatizing experience. They also reported receiving support to find housing, access food, obtain ID, and other needs. However, participants worried about long term program sustainability. CONCLUSIONS Participants in the safer supply program overwhelmingly appreciated it and felt it was lifesaving, and unlike other healthcare or treatment services they had previously accessed. Participants raised concerns that unless a wider variety of medications and ability to consume them by multiple routes of administration became available, safer supply programs would remain unable to completely replace substances from unregulated markets.
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Affiliation(s)
- Gillian Kolla
- Memorial University, St. John's, Canada.
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, Canada.
| | - Bernie Pauly
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, Canada
| | | | | | - Corey Ranger
- AVI Health and Community Services, Victoria, Canada
| | - Jane McCall
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, Canada
| | | | - Kim Toombs
- AVI Health and Community Services, Victoria, Canada
| | | | - Marion Selfridge
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, Canada
| | - Karen Urbanoski
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, Canada
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Pauly BB, Kurz M, Dale LM, Macevicius C, Kalicum J, Pérez DG, McCall J, Urbanoski K, Barker B, Slaunwhite A, Lindsay M, Nosyk B. Implementation of pharmaceutical alternatives to a toxic drug supply in British Columbia: A mixed methods study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 161:209341. [PMID: 38490334 DOI: 10.1016/j.josat.2024.209341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 01/15/2024] [Accepted: 03/12/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND North America has been in an unrelenting overdose crisis for almost a decade. British Columbia (BC), Canada declared a public health emergency due to overdoses in 2016. Risk Mitigation Guidance (RMG) for prescribing pharmaceutical opioids, stimulants and benzodiazepine alternatives to the toxic drug supply ("safer supply") was implemented in March 2020 in an attempt to reduce harms of COVID-19 and overdose deaths in BC during dual declared public health emergencies. Our objective was to describe early implementation of RMG among prescribers in BC. METHODS We conducted a convergent mixed methods study drawing population-level linked administrative health data and qualitative interviews with 17 prescribers. The Consolidated Framework for Implementation Research (CFIR) informs our work. The study utilized seven linked databases, capturing the characteristics of prescribers for people with substance use disorder to describe the characteristics of those prescribing under the RMG using univariate summary statistics and logistic regression analysis. For the qualitative analysis, we drew on interpretative descriptive methodology to identify barriers and facilitators to implementation. RESULTS Analysis of administrative databases demonstrated limited uptake of the intervention outside large urban centres and a highly specific profile of urban prescribers, with larger and more complex caseloads associated with RMG prescribing. Nurse practitioners were three times more likely to prescribe than general practitioners. Qualitatively, the study identified five themes related to the five CFIR domains: 1) RMG is helpful but controversial; 2) Motivations and challenges to prescribing; 3) New options and opportunities for care but not enough to 'win the arms race'; 4) Lack of implementation support and resources; 5) Limited infrastructure. CONCLUSIONS BC's implementation of RMG was limited in scope, prescriber uptake and geographic scale up. Systemic, organizational and individual barriers and facilitators point to the importance of engaging professional regulatory colleges, implementation planning and organizational infrastructure to ensure effective implementation and adaptation to context.
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Affiliation(s)
- Bernadette Bernie Pauly
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada; University of Victoria School of Nursing, Box 1700 Stn CSC, Victoria, BC 250, Canada.
| | - Megan Kurz
- Centre for Advancing Health Outcomes, Providence Health Care, 570-1081 Burrard Street, Vancouver, BC V6Z IY6b, Canada.
| | - Laura M Dale
- Centre for Advancing Health Outcomes, Providence Health Care, 570-1081 Burrard Street, Vancouver, BC V6Z IY6b, Canada.
| | - Celeste Macevicius
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada; University of Victoria School of Public Health and Social Policy, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada.
| | - Jeremy Kalicum
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada; University of Victoria School of Public Health and Social Policy, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada.
| | - Daniel Gudiño Pérez
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada; University of Victoria School of Public Health and Social Policy, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada.
| | - Jane McCall
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada
| | - Karen Urbanoski
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada; University of Victoria School of Public Health and Social Policy, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada.
| | - Brittany Barker
- School of Public Health and Social Policy, University of Victoria, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada; First Nations Health Authority, 501 - 100 Park Royal South, 170-6371 Crescent Road, Coast Salish Territory (West Vancouver), BC V7T 1A2, Canada; Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 11300, 8888 University Drive, Burnaby, B.C. V5A 1S6, Canada.
| | - Amanda Slaunwhite
- BC Centre for Disease Control, 655 W 12th Ave, Vancouver, BC V5Z 4R4, Canada; School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC V6T 1Z3, Canada; Centre for Advancing Health Outcomes, 570-1081 Burrard Street, St. Paul's Hospital, Vancouver, BC V6Z1Y6, Canada.
| | - Morgan Lindsay
- Canadian Institute for Substance Use Research, University of Victoria, 2300 McKenzie Ave, Victoria, BC V8N 5M8, Canada.
| | - Bohdan Nosyk
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 11300, 8888 University Drive, Burnaby, B.C. V5A 1S6, Canada; Centre for Advancing Health Outcomes, Providence Health Care, 570-1081 Burrard Street, St. Paul's Hospital, Vancouver, BC V6Z1Y6, Canada.
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Myklebust LH, Eide D, Arnevik EA, Dadras O, De Pirro S, Ellefsen R, Fadnes LT, Hesse M, Kvamme TL, Melis F, Oldervoll A, Thylstrup B, Wusthoff LEC, Clausen T. Evaluation of heroin-assisted treatment in Norway: protocol for a mixed methods study. BMC Health Serv Res 2024; 24:398. [PMID: 38553691 PMCID: PMC10981318 DOI: 10.1186/s12913-024-10767-w] [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: 11/24/2023] [Accepted: 02/21/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Opioid agonist treatment (OAT) for patients with opioid use disorder (OUD) has a convincing evidence base, although variable retention rates suggest that it may not be beneficial for all. One of the options to include more patients is the introduction of heroin-assisted treatment (HAT), which involves the prescribing of pharmaceutical heroin in a clinical supervised setting. Clinical trials suggest that HAT positively affects illicit drug use, criminal behavior, quality of life, and health. The results are less clear for longer-term outcomes such as mortality, level of function and social integration. This protocol describes a longitudinal evaluation of the introduction of HAT into the OAT services in Norway over a 5-year period. The main aim of the project is to study the individual, organizational and societal effects of implementing HAT in the specialized healthcare services for OUD. METHODS The project adopts a multidisciplinary approach, where the primary cohort for analysis will consist of approximately 250 patients in Norway, observed during the period of 2022-2026. Cohorts for comparative analysis will include all HAT-patients in Denmark from 2010 to 2022 (N = 500) and all Norwegian patients in conventional OAT (N = 8300). Data comes from individual in-depth and semi-structured interviews, self-report questionnaires, clinical records, and national registries, collected at several time points throughout patients' courses of treatment. Qualitative analyses will use a flexible inductive thematic approach. Quantitative analyses will employ a wide array of methods including bi-variate parametric and non-parametric tests, and various forms of multivariate modeling. DISCUSSION The project's primary strength lies in its comprehensive and longitudinal approach. It has the potential to reveal new insights on whether pharmaceutical heroin should be an integral part of integrated conventional OAT services to individually tailor treatments for patients with OUD. This could affect considerations about drug treatment even beyond HAT-specific topics, where an expanded understanding of why some do not succeed with conventional OAT will strengthen the knowledge base for drug treatment in general. Results will be disseminated to the scientific community, clinicians, and policy makers. TRIAL REGISTRATION The study was approved by the Norwegian Regional Committee for Medical and Health Research Ethics (REK), ref.nr.:195733.
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Affiliation(s)
- Lars Henrik Myklebust
- Norwegian Centre for Addiction Research, Faculty of Medicine, University of Oslo, Kirkevegen 166, Building 45, NO-0407, Oslo, Norway.
| | - Desiree Eide
- Norwegian Centre for Addiction Research, Faculty of Medicine, University of Oslo, Kirkevegen 166, Building 45, NO-0407, Oslo, Norway
| | - Espen A Arnevik
- Section for Clinical Addiction Research, Oslo University Hospital, P.b 4950 Nydalen, NO-0424, Oslo, Norway
| | - Omid Dadras
- Bergen Addiction Research Group, Department of Addiction Medicine, Haukeland University Hospital, P.b 1400, NO-5021, Bergen, Norway
| | - Silvana De Pirro
- Norwegian Centre for Addiction Research, Faculty of Medicine, University of Oslo, Kirkevegen 166, Building 45, NO-0407, Oslo, Norway
- Department of Physiology and Pharmacology "V. Erspamer," La Sapienza, University of Rome, P. Ie Aldo Moro 5, 00185, Rome, Italy
| | - Rune Ellefsen
- Section for Clinical Addiction Research, Oslo University Hospital, P.b 4950 Nydalen, NO-0424, Oslo, Norway
| | - Lars T Fadnes
- Bergen Addiction Research Group, Department of Addiction Medicine, Haukeland University Hospital, P.b 1400, NO-5021, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, P.b 7804, NO-5020, Bergen, Norway
| | - Morten Hesse
- Centre for Alcohol and Drug Research, Aarhus University, Bartholins Allé 10, DK-8000, Aarhus, Denmark
| | - Timo L Kvamme
- Centre for Alcohol and Drug Research, Aarhus University, Bartholins Allé 10, DK-8000, Aarhus, Denmark
| | - Francesca Melis
- Norwegian Centre for Addiction Research, Faculty of Medicine, University of Oslo, Kirkevegen 166, Building 45, NO-0407, Oslo, Norway
| | - Ann Oldervoll
- Norwegian Centre for Addiction Research, Faculty of Medicine, University of Oslo, Kirkevegen 166, Building 45, NO-0407, Oslo, Norway
| | - Birgitte Thylstrup
- Centre for Alcohol and Drug Research, Aarhus University, Bartholins Allé 10, DK-8000, Aarhus, Denmark
| | - Linda E C Wusthoff
- Norwegian Centre for Addiction Research, Faculty of Medicine, University of Oslo, Kirkevegen 166, Building 45, NO-0407, Oslo, Norway
- Section for Clinical Addiction Research, Oslo University Hospital, P.b 4950 Nydalen, NO-0424, Oslo, Norway
| | - Thomas Clausen
- Norwegian Centre for Addiction Research, Faculty of Medicine, University of Oslo, Kirkevegen 166, Building 45, NO-0407, Oslo, Norway
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Melis F, Hesse M, Eide D, Thylstrup B, Tjagvad C, Brummer JE, Clausen T. Who receives heroin-assisted treatment? A comparison of patients receiving opioid maintenance treatment in Denmark. Drug Alcohol Depend 2024; 254:111051. [PMID: 38091901 DOI: 10.1016/j.drugalcdep.2023.111051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/20/2023] [Accepted: 11/26/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND Since 2010, heroin-assisted treatment (HAT) has been one of the treatment options available to people with opioid use disorder (OUD) in Denmark. This study aimed to characterize HAT patients at treatment start and compare their individual characteristics to those of patients entering traditional opioid maintenance treatment (OMT) with methadone or buprenorphine during the same period. METHODS Patients who initiated HAT or OMT with methadone or buprenorphine in Denmark from 2010 to 2018 were included (n=6798). Multiple national registers were linked to compare treatment groups in terms of socio-demographic variables, previous OUD treatment episodes, hospital-based care, and criminal conviction history. RESULTS Nearly all HAT patients had a history of methadone treatment (91%) and half had residential treatment experience (48%). In the year previous to admission, HAT patients recorded the highest percentages of non-fatal overdoses (12%) and chronic hepatitis C diagnoses (16%), and the lowest percentages of psychiatric disorders (11%) compared to traditional OMT patients. Criminal convictions were also common: 39% of the HAT group had committed a property crime and 18% a drug-related crime the year before HAT entry. During the study period, an overall reduction in OMT enrollments for each year was recorded. The HAT proportion to the total remained fairly stable (4%-10%), while the buprenorphine proportion increased. CONCLUSIONS In Denmark, OMT patients exhibited numerous vulnerabilities at treatment start, and among the patient groups, HAT patients were the most burdened. HAT seems to reach the target group and adhere to formulated eligibility criteria.
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Affiliation(s)
- Francesca Melis
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, Norway.
| | - Morten Hesse
- Centre for Alcohol and Drug, Research Aarhus UniversityTuborgvej 164, Copenhagen, NV, 2400, Denmark.
| | - Desiree Eide
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, Norway.
| | - Birgitte Thylstrup
- Centre for Alcohol and Drug, Research Aarhus UniversityTuborgvej 164, Copenhagen, NV, 2400, Denmark.
| | - Christian Tjagvad
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, Norway.
| | - Julie Elizabeth Brummer
- Centre for Alcohol and Drug, Research Aarhus UniversityTuborgvej 164, Copenhagen, NV, 2400, Denmark.
| | - Thomas Clausen
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, Norway.
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Schwarz T, Anzenberger J, Busch M, Gmel G, Kraus L, Krausz M, Labhart F, Meyer M, Schaub MP, Westenberg JN, Uhl A. Opioid agonist treatment in transition: A cross-country comparison between Austria, Germany and Switzerland. Drug Alcohol Depend 2024; 254:111036. [PMID: 38091902 DOI: 10.1016/j.drugalcdep.2023.111036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/14/2023] [Accepted: 11/16/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND AND AIMS OAT is a well developed and successful treatment strategy for opioid dependent patients in Europe. It has significantly contributed to the fight against the HIV and HCV pandemics, leading to an increased life expectancy in this population. Building on the OAT experiences in Austria, Germany, and Switzerland and their models of care, the objective of this study is to analyse experiences and changes in patient structures to identify necessary adaptations for the system of care. METHODS We analysed national register-based data from patients receiving OAT during the period spanning from 2010 to 2020 in Austria, Germany (cases), and Switzerland. We examined and compared OAT policies and practice at national levels through a review of literature and publicly available policy documents. RESULTS Across these three countries, the life expectancy of OAT patients increased substantially. The mean age increased from 33.0 in 2010 to 39.1 in 2020 in Austria, from 35.6 years to 41.5 years in Germany (cases), and from 39.6 to 47.1 in Switzerland, respectively. In all three countries, the percentage of patients/cases aged 60 years and older increased more than tenfold between 2010 and 2020. CONCLUSIONS Integrated support models, reliable care structures, internationally comparable high treatment coverage, flexible prescribing practices, and a wide range of available OAT medications are successful strategies. The experiences in these countries indicate that it is possible to address the complex and chronic nature of opioid dependence and its concurrent mental and physical health challenges, resulting in an increasing life expectancy of OAT patients.
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Affiliation(s)
- Tanja Schwarz
- Gesundheit Österreich GmbH, Austrian National Public Health Institute, Vienna, Austria; Doctoral Programme Meduni Vienna, Medical University of Vienna, Spitalgasse 23, Vienna 1090, Austria.
| | - Judith Anzenberger
- Gesundheit Österreich GmbH, Austrian National Public Health Institute, Vienna, Austria
| | - Martin Busch
- Gesundheit Österreich GmbH, Austrian National Public Health Institute, Vienna, Austria
| | - Gerhard Gmel
- Addiction Switzerland, Lausanne, Switzerland; Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ludwig Kraus
- IFT Institut für Therapieforschung, Mental Health and Addiction Research, Munich, Germany; Department of Public Health Sciences, Centre for Social Research on Alcohol and Drugs, Stockholm University, Stockholm, Sweden; Institute of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary; Centre of Interdisciplinary Addiction Research (ZIS), Department of Psychiatry and Psychotherapy University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Krausz
- University of British Columbia, Faculty of Medicine, Department of Psychiatry, Vancouver, BC, Canada
| | - Florian Labhart
- Psychiatric University Clinic Basel, University of Basel, Basel, Switzerland
| | - Maximilian Meyer
- Psychiatric University Clinic Basel, University of Basel, Basel, Switzerland
| | - Michael P Schaub
- Swiss Research Institute for Public Health and Addiction, Zurich, Switzerland
| | - Jean N Westenberg
- Addiction Switzerland, Lausanne, Switzerland; University of British Columbia, Faculty of Medicine, Department of Psychiatry, Vancouver, BC, Canada
| | - Alfred Uhl
- Gesundheit Österreich GmbH, Austrian National Public Health Institute, Vienna, Austria; Sigmund Freud University Vienna, Vienna, Austria
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Friedmann Z, Kinkel HT, Kühner C, Zsolnai A, Mick I, Binder A. Supervised on-site dosing in injectable opioid agonist treatment-considering the patient perspective. Findings from a cross-sectional interview study in two German cities. Harm Reduct J 2023; 20:162. [PMID: 37915058 PMCID: PMC10619267 DOI: 10.1186/s12954-023-00896-6] [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: 05/11/2023] [Accepted: 10/24/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND Injectable opioid agonist treatment (iOAT) is an effective option to support people living with opioid use disorder (OUD) who have not sufficiently benefitted from oral OAT. However, iOAT has been criticised based on theoretical and practical grounds for its dosing policies: Current regulations demand supervised, on-site application and require patients to frequently visit their treatment facility. The current study aims to investigate how patients experience on-site application and derive strategies to enhance the acceptability and effectiveness of iOAT-delivery. METHODS This article is based on semi-structured interviews with 27 individuals currently or previously in iOAT in two German outpatient iOAT-clinics. We undertook an inductive qualitative content analysis, which included blinded, independent coding and the analysis of individual cases. RESULTS Comments regarding on-site application and daily visits to the clinic were grouped into positive and negative aspects, iOAT as the best alternative option, facilitators of daily visits, and suggestions for improvement. Positive aspects took the factors stability and social support in regard. Negative aspects ranged from general inconveniences to major impediments to individuals' daily lives and towards achieving psychosocial goals. Participants reported rigorous adherence to iOAT's treatment regime, often due to a perceived lack of alternative options. Meeting iOAT's demands was eased by the patients' coping-strategies and through facilitating measures implemented by iOAT-clinics. Despite acknowledgement of the potential detriments from easing regulations, take-home arrangements were frequently suggested by participants to improve iOAT. CONCLUSIONS Being required to attend the clinic for supervised iOAT-application is not experienced uniformly. While clinics can support their patients to cope with strict regulations, alternative approaches to iOAT-application should be considered to accommodate patients' individual needs. Examples from other treatment modalities (e.g., remote supervision and delivery services) might aid to reconcile individualisation while providing adequate safety measures and improve iOAT in the long term.
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Affiliation(s)
- Zoe Friedmann
- Charité Universitätsmedizin Berlin (Medical University Hospital Charité Berlin), Charitéplatz 1, 10117, Berlin, Germany.
| | - Hans-Tilmann Kinkel
- Praxiskombinat Neubau, Schwerpunktpraxis für Suchtmedizin (Outpatient Clinic for Addiction Medicine), Ruschestraße 103, 10365, Berlin, Germany
| | - Claudia Kühner
- Schwerpunktpraxis für Suchtmedizin Stuttgart (Outpatient Clinic for Addiction Medicine), Kriegsbergstraße 40, 70174, Stuttgart, Germany
| | - Andreas Zsolnai
- Schwerpunktpraxis für Suchtmedizin Stuttgart (Outpatient Clinic for Addiction Medicine), Kriegsbergstraße 40, 70174, Stuttgart, Germany
| | - Inge Mick
- Department of Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin (Medical University Hospital Charité Berlin), Charitéplatz 1, 10117, Berlin, Germany
| | - Annette Binder
- Department of General Psychiatry and Psychotherapy, Addiction Medicine and Addiction Research Section, University Hospital Tuebingen, University of Tuebingen, Calwerstraße 14, 72076, Tuebingen, Germany
- DZPG (German Centre for Mental Health), Tuebingen, Germany
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Meyer M, Westenberg JN, Jang KL, Choi F, Schreiter S, Mathew N, King C, Lang UE, Vogel M, Krausz RM. Shifting drug markets in North America - a global crisis in the making? Int J Ment Health Syst 2023; 17:36. [PMID: 37880722 PMCID: PMC10598952 DOI: 10.1186/s13033-023-00601-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 09/27/2023] [Indexed: 10/27/2023] Open
Abstract
Understanding drug market dynamics and their underlying driving factors is paramount to developing effective responses to the overdose crisis in North America. This paper summarises the distinct drug market trends observed locally and internationally over the past decade to extrapolate future drug market trajectories. The emergence of fentanyl on North American street markets from 2014 onwards led to a shift of street drug use patterns. Previously perceived as contaminants, novel synthetic opioids became the drugs of choice and a trend towards higher potency was observed across various substance classes. The diversification of distribution strategies as well as the regionalisation and industrialisation of production followed basic economic principles that were heavily influenced by prosecution and policy makers. Particularly, the trend towards higher potency is likely most indicative of what to expect from future illicit drug market developments. Nitazenes and fentanyl-analogues, several times more potent than fentanyl itself, are increasingly detected in toxicological testing and have the potential of becoming the drugs of choice in the future. The dynamic of drug import and local production is less clear and influenced by a multitude of factors like precursor availability, know-how, infrastructure, and the success of local drug enforcement strategies. Drug market dynamics and the current trajectory towards ultrapotent opioids need to be recognised by legislation, enforcement, and the health care system to prepare effective responses. Without significant improvements in treatment access, the implementation of preventative approaches and early warning systems, the mortality rate will continue to increase. Furthermore, there is no mechanism in place preventing the currently North American focused overdose crisis to spread to other parts of the globe, particularly Europe. A system of oversight, research, and treatment is needed to address mortality rates of historic proportions and prevent further harm.
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Affiliation(s)
- Maximilian Meyer
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada.
- University Psychiatric Clinics Basel, University of Basel, Basel, Switzerland.
| | - Jean N Westenberg
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada
| | - Kerry L Jang
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada
| | - Fiona Choi
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada
| | - Stefanie Schreiter
- Department of Psychiatry and Neurosciences, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nickie Mathew
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada
| | - Conor King
- Victoria Police Department, Victoria, Canada
| | - Undine E Lang
- University Psychiatric Clinics Basel, University of Basel, Basel, Switzerland
| | - Marc Vogel
- University Psychiatric Clinics Basel, University of Basel, Basel, Switzerland
| | - R Michael Krausz
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada
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9
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Ellefsen R, Wüsthoff LEC, Arnevik EA. Patients' satisfaction with heroin-assisted treatment: a qualitative study. Harm Reduct J 2023; 20:73. [PMID: 37312181 DOI: 10.1186/s12954-023-00808-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/06/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Heroin-assisted treatment (HAT) involves supervised dispensing of medical heroin (diacetylmorphine) for people with opioid use disorder. Clinical evidence has demonstrated the effectiveness of HAT, but little is known about the self-reported satisfaction among the patients who receive this treatment. This study presents the first empirical findings about the patients' experiences of, and satisfaction with, HAT in the Norwegian context. METHODS Qualitative in-depth interviews with 26 patients in HAT were carried out one to two months after their enrollment. Analysis sought to identify the main benefits and challenges that the research participants experienced with this treatment. An inductive thematic analysis was conducted to identify the main areas of benefits and challenges. The benefits were weighed against the challenges in order to assess the participants' overall level of treatment satisfaction. RESULTS Analysis identified three different areas of experienced benefits and three areas of challenges of being in this treatment. It outlines how the participants' everyday lives are impacted by being in the treatment and how this, respectively, results from the treatment's medical, relational, or configurational dimensions. We found an overall high level of treatment satisfaction among the participants. The identification of experienced challenges reveals factors that reduce satisfaction and thus may hinder treatment retention and positive treatment outcomes. CONCLUSIONS The study demonstrates a novel approach to qualitatively investigate patients' treatment satisfaction across different treatment dimensions. The findings have implications for clinical practice by pointing out key factors that inhibit and facilitate patients' satisfaction with HAT. The identified importance of the socio-environmental factors and relational aspect of the treatment has further implications for the provision of opioid agonist treatment in general.
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Affiliation(s)
- Rune Ellefsen
- Section for Clinical Addiction Research, Oslo University Hospital, PO Box 4959 Nydalen, 0424, Oslo, Norway.
| | - Linda Elise Couëssurel Wüsthoff
- Section for Clinical Addiction Research, Oslo University Hospital, PO Box 4959 Nydalen, 0424, Oslo, Norway
- The Norwegian Centre for Addiction Research, University of Oslo, PO Box 1039 Blindern, 0315, Oslo, Norway
| | - Espen Ajo Arnevik
- Section for Clinical Addiction Research, Oslo University Hospital, PO Box 4959 Nydalen, 0424, Oslo, Norway
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10
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Blawatt S, Arreola LAG, Magel T, MacDonald S, Harrison S, Schechter MT, Oviedo-Joekes E. Changes in daily dose in open-label compared to double-blind: The role of clients' expectations in injectable opioid agonist treatment. Addict Behav Rep 2023; 17:100490. [PMID: 37124402 PMCID: PMC10140796 DOI: 10.1016/j.abrep.2023.100490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 04/03/2023] [Accepted: 04/11/2023] [Indexed: 05/02/2023] Open
Abstract
Introduction Though double-blind studies have indicated that hydromorphone and diacetylmorphine produce similar effects when administered through injectable opioid agonist treatment (iOAT) programs, participant preference may influence some aspects of medication dispensation such as dose. Methods This is a retrospective longitudinal analysis. Participants (n = 131) were previously enrolled in a double-blind clinical trial for iOAT who continued to receive treatment in an open-label follow up study. Data included medication dispensation records from 2012 to 2020. Using linear regression and paired t-tests, average daily dose totals of hydromorphone and diacetylmorphine were examined comparatively between double-blind and open-label periods. A subgroup analysis explored dose difference by preference using the proxy, blinding guess, a variable used to facilitate the measurement of treatment masking during the clinical trial by asking which medication the participant thought they received. Results During the open-label period, participants prescribed diacetylmorphine received 49.5 mg less than during the double-blind period (95% CI -12.6,-86.4). Participants receiving hydromorphone did not see a significant dose decrease. Participants who guessed they received hydromorphone during the clinical trial, but learned they were on diacetylmorphine during the open-label period, saw a decrease in total daily dose of 78.3 mg less (95% CI -134.3,-22.4) during the open-label period. Conclusion If client preference is considered in the treatment of chronic opioid use disorder, clients may be able to better moderate their dose to suit their individual needs. Together with their healthcare providers, clients can participate in their treatment trajectories collaboratively to optimize client outcomes and promote person-centered treatment options.
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Affiliation(s)
- Sarin Blawatt
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575-1081 Burrard St., Vancouver, BC V6Z 1Y6, Canada
| | | | - Tianna Magel
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada
| | - Scott MacDonald
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver BCV6B 1G6, Canada
| | - Scott Harrison
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver BCV6B 1G6, Canada
| | - Martin T. Schechter
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575-1081 Burrard St., Vancouver, BC V6Z 1Y6, Canada
| | - Eugenia Oviedo-Joekes
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575-1081 Burrard St., Vancouver, BC V6Z 1Y6, Canada
- Corresponding author at: St. Paul's Hospital, 575-1081 Burrard St., Vancouver, BC V6Z 1Y6, Canada.
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11
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Oviedo-Joekes E, Dobischok S, Carvajal J, MacDonald S, McDermid C, Klakowicz P, Harrison S, LaJeunesse J, Chow N, Brown M, Gill S, Schechter M. Clients' experiences on North America's first take-home injectable opioid agonist treatment (iOAT) program: a qualitative study. BMC Health Serv Res 2023; 23:553. [PMID: 37237256 DOI: 10.1186/s12913-023-09558-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND To support public health measures during the COVID-19 pandemic, oral opioid agonist treatment (OAT) take-home doses were expanded in Western countries with positive results. Injectable OAT (iOAT) take-home doses were previously not an eligible option, and were made available for the first time in several sites to align with public health measures. Building upon these temporary risk-mitigating guidelines, a clinic in Vancouver, BC continued to offer two of a possible three daily doses of take-home injectable medications to eligible clients. The present study explores the processes through which take-home iOAT doses impacted clients' quality of life and continuity of care in real-life settings. METHODS Three rounds of semi-structured qualitative interviews were conducted over a period of seventeen months beginning in July 2021 with eleven participants receiving iOAT take-home doses at a community clinic in Vancouver, British Columbia. Interviews followed a topic guide that evolved iteratively in response to emerging lines of inquiry. Interviews were recorded, transcribed, and then coded using NVivo 1.6 using an interpretive description approach. RESULTS Participants reported that take-home doses granted them the freedom away from the clinic to have daily routines, form plans, and enjoy unstructured time. Participants appreciated the greater privacy, accessibility, and ability to engage in paid work. Furthermore, participants enjoyed greater autonomy to manage their medication and level of engagement with the clinic. These factors contributed to greater quality of life and continuity of care. Participants shared that their dose was too essential to divert and that they felt safe transporting and administering their medication off-site. In the future, all participants would like more accessible treatment such as access longer take-home prescriptions (e.g., one week), the ability to pick-up at different and convenient locations (e.g., community pharmacies), and a medication delivery service. CONCLUSIONS Reducing the number of daily onsite injections from two or three to only one revealed the diversity of rich and nuanced needs that added flexibility and accessibility in iOAT can meet. Actions such as licencing diverse opioid medications/formulations, medication pick-up at community pharmacies, and a community of practice that supports clinical decisions are necessary to increase take-home iOAT accessibility.
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Affiliation(s)
- Eugenia Oviedo-Joekes
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada.
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada.
| | - Sophia Dobischok
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada
| | - José Carvajal
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada
| | - Scott MacDonald
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Cheryl McDermid
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Piotr Klakowicz
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Scott Harrison
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Julie LaJeunesse
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Nancy Chow
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Murray Brown
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Sam Gill
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Martin Schechter
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
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12
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Riley F, Harris M, Poulter HL, Moore HJ, Ahmed D, Towl G, Walker T. 'This is hardcore': a qualitative study exploring service users' experiences of Heroin-Assisted Treatment (HAT) in Middlesbrough, England. Harm Reduct J 2023; 20:66. [PMID: 37173697 PMCID: PMC10182620 DOI: 10.1186/s12954-023-00785-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 04/16/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Heroin-Assisted Treatment (HAT) is well evidenced internationally to improve health and social outcomes for people dependent on opioids who have not been helped by traditional treatment options. Despite this evidence base, England has been slow to implement HAT. The first service outside of a trial setting opened in 2019, providing twice-daily supervised injections of medical-grade heroin (diamorphine) to a select sample of high-risk heroin users in Middlesbrough. This paper explores their experiences, including the negotiation of the strict regularly controls required of a novel intervention in the UK context. METHODS We conducted in-depth interviews with service providers and users of the Middlesbrough HAT service between September and November 2021. Data from each group were thematically analysed and reported separately. This paper details the experiences of the twelve heroin dependent men and women accessing HAT. RESULTS Participants' accounts of HAT treatment evidenced a tension between the regulatory constraints and uncertainty of treatment provision, and the positive outcomes experienced through supportive service provision and an injectable treatment option. Limited confidence was held in treatment efficacy, longevity of funding, and personal capacity for treatment success. This was counteracted by a strong motivation to cease engagement with the illicit drug market. While attendance requirements placed restrictions on daily activities, participants also experienced benefits from strong, supportive bonds built with the service providers through their continued engagement. CONCLUSIONS The Middlesbrough HAT programme provided benefits to a high-risk population of opioid dependent people who were unable or disinclined to participate in conventional opioid substitution treatments. The findings in this paper highlight the potential for service modifications to further enhance engagement. The closure of this programme in 2022 prohibits this opportunity for the Middlesbrough community, but holds potential to inform advocacy and innovation for future HAT interventions in England.
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Affiliation(s)
- Fleur Riley
- Department of Psychology, Durham University, Durham, DH1 3LE, England, UK.
| | - Magdalena Harris
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, England, UK
| | - Hannah Louise Poulter
- School of Social Sciences, Humanities and Law, Teesside University, Middlesbrough, TS1 3BX, England, UK
| | - Helen J Moore
- School of Social Sciences, Humanities and Law, Teesside University, Middlesbrough, TS1 3BX, England, UK
| | - Daniel Ahmed
- Foundations Medical Practice, Acklam Road, Middlesbrough, TS5 4EQ, England, UK
| | - Graham Towl
- Department of Psychology, Durham University, Durham, DH1 3LE, England, UK
| | - Tammi Walker
- Department of Psychology, Durham University, Durham, DH1 3LE, England, UK
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13
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Poulter HL, Walker T, Ahmed D, Moore HJ, Riley F, Towl G, Harris M. More than just 'free heroin': Caring whilst navigating constraint in the delivery of diamorphine assisted treatment. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 116:104025. [PMID: 37062231 DOI: 10.1016/j.drugpo.2023.104025] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 03/29/2023] [Accepted: 04/02/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND In 2020, drug related deaths in the United Kingdom (UK) reached the highest rate in over 25 years, with hospitalisations and deaths particularly impacting people who use illicit opioids such as heroin. Treatment systems are increasingly required to be innovative to engage the most vulnerable at risk from premature morbidity and mortality. Heroin Assisted Treatment (HAT) is an alternative treatment modality for people for whom more traditional forms of opioid substitution therapy, such as methadone, have been ineffective. Middlesbrough, a town in the North-East England, was home to the first service in the UK to implement HAT outside of a clinical trial setting which closed for operation in November 2022. METHODS Qualitative in-depth interviews with patients and health care providers (n =17) involved in the delivery of HAT were undertaken during 2021. This paper focuses on the health care provider interviews, the majority of which took place remotely. Interviews were audio recorded and thematically analysed. RESULTS Health care providers navigated multiple layers of constraint during HAT implementation and delivery. We explore this in relation to three themes: 1) Negotiating risk and safety within treatment 2) More than a prescription: care beyond diamorphine 3) Internal and external delivery barriers and impact on treatment acceptability, identity and longevity. Negotiating and managing risks of polysubstance use was a complex task. Benefits regarding access to holistic care, improved therapeutic and social relationships were recognised by practitioners. The rigorous delivery schedule was the biggest barrier to engagement. Outside the treatment room, socio-structural factors posed additional challenges. CONCLUSION Despite some operational complexities, health care providers viewed HAT as an effective method of engaging a high risk population with drug treatment services, with holistic benefits for clients over and above the treatment of opioid dependency. Findings will inform advocacy and innovation for future HAT interventions in England.
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Affiliation(s)
- Hannah Louise Poulter
- School of Social Sciences, Humanities and Law, Teesside University, Middlesbrough, TS1 3BX, United Kingdom.
| | - Tammi Walker
- Durham University, Department of Psychology, England, UK
| | - Danny Ahmed
- Clinical Lead, Foundations Medical Practice, Acklam Road, Middlesbrough, TS5 4EQ, United Kingdom
| | - Helen J Moore
- School of Social Sciences, Humanities and Law, Teesside University, Middlesbrough, TS1 3BX, United Kingdom
| | - Fleur Riley
- Durham University, Department of Psychology, England, UK
| | - Graham Towl
- Durham University, Department of Psychology, England, UK
| | - Magdalena Harris
- London School of Hygiene & Tropical Medicine, Department of Public Health, Environments and Society, England, UK
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14
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Meyer M, Westenberg JN, Krausz RM. The Fentanyl System Shock - Are There Lessons to Learn From the COVID-19 System Shock Framework? Comment on "The COVID-19 System Shock Framework: Capturing Health System Innovation During the COVID-19 Pandemic". Int J Health Policy Manag 2023; 12:7409. [PMID: 37579419 PMCID: PMC10461848 DOI: 10.34172/ijhpm.2023.7409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 02/13/2023] [Indexed: 08/16/2023] Open
Abstract
The Sydney Children's Hospitals Network (SCHN) addressed the challenges of the COVID-19 pandemic by implementing innovative changes which made their health system resilient and responsive. For other healthcare systems, there are important takeaways. In the United States and Canada, an urgent widespread response is needed to address the overdose crisis, driven by potent synthetic opioids (ie, fentanyl and its derivates). We project the COVID-19 System Shock Framework (CSSF) on to the North American healthcare systems and suggest a Fentanyl System Shock Framework, which provides a framework for necessary changes and innovations to address the overdose crisis. To become resilient to the fentanyl system shock, core components as well as overarching values, health policy, and online technologies need to be adapted to reduce the death count and meet the evolving needs of marginalised individuals who use opioid. Future research should focus on scientifically assessing such implementations to guide evidence-based decision making.
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Affiliation(s)
- Maximilian Meyer
- University Psychiatric Clinics Basel, University of Basel, Basel, Switzerland
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Jean N. Westenberg
- University Psychiatric Clinics Basel, University of Basel, Basel, Switzerland
| | - R. Michael Krausz
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
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15
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Magel T, Matzinger E, Blawatt S, Harrison S, MacDonald S, Amara S, Metcalfe R, Bansback N, Byres D, Schechter M, Oviedo-Joekes E. How injectable opioid agonist treatment (iOAT) care could be improved? service providers and stakeholders’ perspectives. DRUGS: EDUCATION, PREVENTION AND POLICY 2023. [DOI: 10.1080/09687637.2023.2176287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
- Tianna Magel
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Elizabeth Matzinger
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul’s Hospital, Vancouver, Canada
| | - Sarah Blawatt
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul’s Hospital, Vancouver, Canada
| | - Scott Harrison
- Providence Health Care, Providence Crosstown Clinic, Vancouver, Canada
| | - Scott MacDonald
- Providence Health Care, Providence Crosstown Clinic, Vancouver, Canada
| | - Sherif Amara
- SafePoint Supervised Consumption Site, Fraser Health Authority, Surrey, Canada
| | - Rebecca Metcalfe
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul’s Hospital, Vancouver, Canada
| | - Nick Bansback
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul’s Hospital, Vancouver, Canada
| | - David Byres
- Provincial Health Services Authority, Vancouver, Canada
| | - Martin Schechter
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul’s Hospital, Vancouver, Canada
| | - Eugenia Oviedo-Joekes
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul’s Hospital, Vancouver, Canada
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Vogel M, Meyer M, Westenberg JN, Kormann A, Simon O, Salim Hassan Fadlelseed R, Kurmann M, Bröer R, Devaud N, Sanwald U, Baumgartner S, Binder H, Strasser J, Krausz RM, Beck T, Dürsteler KM, Falcato L. Safety and feasibility of intranasal heroin-assisted treatment: 4-week preliminary findings from a Swiss multicentre observational study. Harm Reduct J 2023; 20:2. [PMID: 36611162 PMCID: PMC9826580 DOI: 10.1186/s12954-023-00731-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 01/03/2023] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Heroin-assisted treatment (HAT) is effective for individuals with severe opioid use disorder (OUD) who do not respond sufficiently to other opioid agonist treatments. It is mostly offered with injectable diacetylmorphine (DAM) or DAM tablets creating a barrier for individuals who need the rapid onset of action but are either unable or unwilling to inject, or primarily snort opioids. To explore another route of administration, we evaluated the safety and feasibility of intranasal (IN) DAM. METHODS This is a multicentre observational cohort study among patients in Swiss HAT. All patients planning to receive IN DAM within the treatment centres were eligible to participate. Participants were either completely switched to IN DAM or received IN DAM in addition to other DAM formulations or opioid agonists. Patients were followed up for four weeks. Sociodemographic characteristics, current HAT regimen, reasons for starting IN DAM, IN DAM doses, number of injection events in the sample, IN DAM continuation rate, and appearance of adverse events and nose-related problems were evaluated. RESULTS Participants (n = 52) reported vein damage, preference for nasal route of administration, and desire of a stronger effect or for a less harmful route of administration as primary reasons for switching to IN DAM. After four weeks, 90.4% of participants (n = 47) still received IN DAM. Weekly average realised injection events decreased by 44.4% from the month before IN DAM initiation to the month following. No severe adverse events were reported. CONCLUSIONS After four weeks, IN DAM was a feasible and safe alternative to other routes of administration for patients with severe OUD in HAT. It addressed the needs of individuals with OUD and reduced injection behaviour. More long-term research efforts are needed to systematically assess efficacy of and patient satisfaction with IN DAM.
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Affiliation(s)
- Marc Vogel
- University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002, Basel, Switzerland.
| | - Maximilian Meyer
- grid.6612.30000 0004 1937 0642University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002 Basel, Switzerland
| | - Jean N. Westenberg
- grid.6612.30000 0004 1937 0642University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002 Basel, Switzerland ,grid.17091.3e0000 0001 2288 9830Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC Canada
| | | | - Olivier Simon
- grid.9851.50000 0001 2165 4204Service of Addiction Medicine, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | | | - Markus Kurmann
- HeGeBe HEROL, Psychiatric Services, Hospitals Solothurn, Olten, Switzerland
| | - Rebecca Bröer
- SuGeBe Gourrama, Psychiatric Services, Hospitals Solothurn, Solothurn, Switzerland
| | | | - Ulrike Sanwald
- Integrierte Suchthilfe Winterthur ISW, Integrated Psychiatry Winterthur, Winterthur, Switzerland
| | | | - Hannes Binder
- Outpatient Clinic for Substance Use Disorders, Psychiatric Clinic Baselland, Reinach, Switzerland
| | - Johannes Strasser
- grid.6612.30000 0004 1937 0642University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002 Basel, Switzerland
| | - R. Michael Krausz
- grid.17091.3e0000 0001 2288 9830Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC Canada
| | - Thilo Beck
- grid.483175.c0000 0004 6008 5851Arud Zentrum Für Suchtmedizin, Zurich, Switzerland
| | - Kenneth M. Dürsteler
- grid.6612.30000 0004 1937 0642University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002 Basel, Switzerland ,grid.7400.30000 0004 1937 0650Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Luis Falcato
- grid.483175.c0000 0004 6008 5851Arud Zentrum Für Suchtmedizin, Zurich, Switzerland
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Meyer M, Westenberg JN, Strasser J, Dürsteler KM, Lang UE, Krausz M, Vogel M. Nasal administration of diacetylmorphine improved the adherence in a patient receiving heroin-assisted treatment. Harm Reduct J 2022; 19:63. [PMID: 35672825 PMCID: PMC9171487 DOI: 10.1186/s12954-022-00644-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/31/2022] [Indexed: 11/24/2022] Open
Abstract
Background Traditional heroin-assisted treatment in Switzerland consists of oral and injectable diacetylmorphine (pharmaceutical heroin) administration. To date, no suitable treatment option is available for patients who crave rapid onset (“rush”) but are either unable to inject or primarily sniff or inhale illicit heroin. We present a patient who successfully switched to intranasal heroin-assisted treatment following several unsuccessful treatment attempts. Case presentation A 29-year-old male with severe opioid use disorder, injection substance use, and concomitant cocaine use, previously prescribed slow-release oral morphine, was started on intravenous diacetylmorphine. Due to complications and harms associated with intravenous injections, nasal diacetylmorphine was prescribed. With this novel route of administration, the patient who had previously been unable to adhere to other OAT options remained in treatment. Health outcomes improved by reduction of injection-related harms, increased adherence to the heroin-assisted treatment regimen, and increased collaboration with the therapeutic staff. Conclusions Nasal heroin-assisted treatment can be a feasible therapeutic option for individuals with severe opioid use disorder who crave the fast onset of effect of diacetylmorphine but are unable to inject intravenously.
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