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Michener PS, Knee A, Wilson D, Boama-Nyarko E, Friedmann PD. Association of random and observed urine drug screening with long-term retention in opioid treatment programs. Drug Alcohol Depend 2024; 255:111067. [PMID: 38183832 PMCID: PMC10956422 DOI: 10.1016/j.drugalcdep.2023.111067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND In the US, opioid treatment providers (OTPs) have wide latitude to perform urine drug screening (UDS) and discharge clients for positive results. OTP clients have identified randomized and directly observed UDS as potentially stigmatizing, but little research has examined the association between UDS modality and retention in OTPs. METHODS This cross-sectional study uses the 2016-2017 NDATSS wave among OTPs that administered methadone. The exposure was a 4-level variable based on whether OTPs had a high percentage (≥ 90% of clients) who experienced randomized, observed, both, or neither modality of UDS. The outcome was the proportion of clients retained in treatment 1 year or longer (long-term retention). Analyses were conducted using fractional logit regression with survey weighting and presented as percentages and 95% confidence intervals. We also present how policies for involuntary clinic discharge modify these effects. RESULTS 150 OTPs were eligible with a median of 310 clients. 40 (27%) OTPs did not highly utilize either randomized or observed UDS, 22 (15%) only highly utilized observed UDS, 42 (28%) only highly utilized randomized UDS and 46 (31%) utilized both practices on ≥ 90% of clients. Adjusted estimates for long-term retention ranged from 57.7% in OTPs that conducted both randomized and observed UDS on ≥ 90% of clients and 70.4% in OTPs that did not highly utilize these practices. Involuntary discharge may moderate this relationship. CONCLUSION Findings showed an association between high utilization of randomized and observed UDS and decreased long-term retention, suggesting that UDS modality may impact long-term OTP retention.
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Affiliation(s)
- Pryce S Michener
- Clinical and Population Health Research Program, Graduate School of Biomedical Sciences University of Massachusetts Chan Medical School, 55 N Lake Ave, Worcester, MA 01655, USA.
| | - Alexander Knee
- Dept. of Medicine, UMass Chan Medical School - Baystate, 759 Chestnut St, Springfield, MA 01199, USA; Epidemiology/Biostatistics Research Core - Baystate Medical Center, Office of Research, 3601 Main Street, Third Floor, Springfield, MA 01199, USA
| | - Donna Wilson
- Dept. of Medicine, UMass Chan Medical School - Baystate, 759 Chestnut St, Springfield, MA 01199, USA; Epidemiology/Biostatistics Research Core - Baystate Medical Center, Office of Research, 3601 Main Street, Third Floor, Springfield, MA 01199, USA
| | - Esther Boama-Nyarko
- Clinical and Population Health Research Program, Graduate School of Biomedical Sciences University of Massachusetts Chan Medical School, 55 N Lake Ave, Worcester, MA 01655, USA
| | - Peter D Friedmann
- Dept. of Medicine, UMass Chan Medical School - Baystate, 759 Chestnut St, Springfield, MA 01199, USA
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Bharat C, Gisev N, Barbieri S, Dobbins T, Larney S, Buizen L, Degenhardt L. Prescription opioid use among people with opioid dependence and concurrent benzodiazepine and gabapentinoid exposure: An analysis of overdose and all-cause mortality. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 123:104287. [PMID: 38088003 DOI: 10.1016/j.drugpo.2023.104287] [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: 07/24/2023] [Revised: 11/30/2023] [Accepted: 12/02/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND Studies investigating mortality risk associated with use of opioid analgesics, benzodiazepines, gabapentinoids, and opioid agonist treatment (OAT) among people with opioid dependence (PWOD) are lacking. This study addresses this gap using a cohort of 37,994 PWOD initiating opioid analgesics between July 2003 and July 2018 in New South Wales, Australia. METHODS Linked administrative records provided data on dispensings, sociodemographics, clinical characteristics, OAT, and mortality. Cox proportional hazards models assessed associations between time-varying measures of individual and concurrent medicine use and OAT with all-cause mortality, accidental opioid overdose, non-drug induced accidents, and non-drug-induced suicide. Opioid analgesic dose effects, expressed as oral morphine equivalents (OMEs) per day, were also examined. OUTCOMES During the study period, 3167 individuals died. Compared with no use, all medicines of interest were associated with increased accidental opioid overdose risk; hazard ratios (HR) ranged from 1.33 (95 % CI: 1.05-1.68) for opioid analgesic use to 6.10 (95 % CI: 4.11-9.06) for opioid analgesic, benzodiazepine and gabapentinoid use. Benzodiazepine use was associated with increased non-drug-induced accidents and non-drug-induced suicides. For all-cause mortality, all combinations of benzodiazepines and gabapentinoids with opioid analgesics were associated with increased risk (aHRs ranged from 1.35 to 2.73). For most medicines/medicine combinations, all-cause mortality risk was reduced when in OAT compared to out of OAT. Higher opioid analgesic doses were associated with increased all-cause mortality (e.g., 90-199 mg vs 1-49 mg OME per day: HR 1.90 [95 % CI: 1.52-2.40]). INTERPRETATION The increased mortality risk associated with benzodiazepines and gabapentinoids among PWOD appear to be reduced when engaged in OAT. A greater focus on encouraging OAT engagement, providing overdose prevention education, and access and coverage of overdose antidotes is necessary to minimise the unintended consequences of medicines use in this population.
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Affiliation(s)
- Chrianna Bharat
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia.
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | | | | | - Sarah Larney
- Université de Montréal and Centre de Recherche du CHUM, Montreal, Canada
| | - Luke Buizen
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
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3
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Rodger L, Nader M, Turner S, Lurie E. Initiation and rapid titration of methadone and slow-release oral morphine (SROM) in an acute care, inpatient setting: a case series. Eur J Med Res 2023; 28:573. [PMID: 38066517 PMCID: PMC10704823 DOI: 10.1186/s40001-023-01538-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/02/2022] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Methadone titration in an outpatient setting typically involves initiation with subtherapeutic doses with slow titration to mitigate the risks of respiratory depression and overdose. In pregnancy, and generally, subtherapeutic doses of methadone and slow titrations are associated with poorer outcomes in terms of treatment retention and ongoing illicit opioid use. We aim to describe rapid titration of OAT in an inpatient setting for pregnant injection opioid users with high opioid tolerance secondary to a fentanyl-based illicit drug supply. METHODS Retrospective case series of patients admitted to a tertiary center with a primary indication of opioid withdrawal and treatment for severe opioid use disorder in pregnancy. RESULTS Twelve women received rapid methadone titrations with or without slow-release oral morphine for opioid use disorder during a total of fifteen hospital admissions. All women included in the study were active fentanyl users (12/12). Methadone dosing was increased rapidly with no adverse events with a median dose at day 7 of 65 mg (IQR 60-70 mg) and median discharge dose of 85 mg (IQR 70-92.5 mg) during their admission for titration. Slow-release oral morphine was used in half of the titration admissions (8/15) with a median dose of 340 mg (IQR 187.5-425 mg) at discharge. The median length of admission was 12 days (IQR 9.5-15). CONCLUSIONS A rapid titration of methadone was completed in an inpatient setting with or without slow-release oral morphine, without adverse events showing feasibility of this protocol for a pregnant population in an inpatient setting. Patients achieved therapeutic doses of methadone (and/or SROM) faster than outpatient counterparts with no known adverse events.
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Affiliation(s)
- Laura Rodger
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Maya Nader
- Department of Family & Community Medicine, University of Toronto, Toronto, Canada
| | - Suzanne Turner
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Erin Lurie
- Department of Family & Community Medicine, University of Toronto, Toronto, Canada.
- Wellesley St-James Town Health Centre, 95 Homewood Ave, Toronto, ON, M4Y 1J4, Canada.
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4
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Brothers TD, Lewer D, Jones N, Colledge-Frisby S, Bonn M, Wheeler A, Grebely J, Farrell M, Hickman M, Hayward A, Degenhardt L. Effect of incarceration and opioid agonist treatment transitions on risk of hospitalisation with injection drug use-associated bacterial infections: A self-controlled case series in New South Wales, Australia. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 122:104218. [PMID: 37813083 DOI: 10.1016/j.drugpo.2023.104218] [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: 05/18/2023] [Revised: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND Transitional times in opioid use, such as release from prison and discontinuation of opioid agonist treatment (OAT), are associated with health harms due to changing drug consumption practices and limited access to health and social supports. Using a self-controlled (within-person) study design, we aimed to understand if these transitions increase risks of injection drug use-associated bacterial infections. METHODS We performed a self-controlled case series among a cohort of people with opioid use disorder (who had all previously accessed OAT) in New South Wales, Australia, 2001-2018. The outcome was hospitalisation with injecting-related bacterial infections. We divided participants' observed days into time windows related to incarceration and OAT receipt. We compared hospitalization rates during focal (exposure) windows and referent (control) windows (i.e., 5-52 weeks continuously not incarcerated or continuously receiving OAT). We estimated adjusted incidence rate ratios (aIRR) using conditional logistic regression, adjusted for time-varying confounders. RESULTS There were 7590 participants who experienced hospitalisation with injecting-related bacterial infections (35% female; median age 38 years; 78% hospitalised with skin and soft-tissue infections). Risk for injecting-related bacterial infections was elevated for two weeks following release from prison (aIRR 1.45; 95%CI 1.22-1.72). Risk was increased during two weeks before (aIRR 1.89; 95%CI 1.59-2.25) and after (aIRR 1.91; 95%CI 1.54-2.36) discontinuation of OAT, and during two weeks before (aIRR 3.63; 95%CI 3.13-4.22) and after (aIRR 2.52; 95%CI 2.09-3.04) OAT initiation. CONCLUSION Risk of injecting-related bacterial infections varies greatly within-individuals over time. Risk is raised immediately after prison release, and around initiation and discontinuation of OAT. Social contextual factors likely contribute to excess risks at transitions in incarceration and OAT exposure.
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Affiliation(s)
- Thomas D Brothers
- National Drug and Alcohol Research Centre (NDARC), University of New South Wales, Australia; UCL Collaborative Centre for Inclusion Health, Department of Epidemiology and Public Health, University College London, United Kingdom; Division of General Internal Medicine, Department of Medicine, Dalhousie University, Canada.
| | - Dan Lewer
- National Drug and Alcohol Research Centre (NDARC), University of New South Wales, Australia; UCL Collaborative Centre for Inclusion Health, Department of Epidemiology and Public Health, University College London, United Kingdom; Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, United Kingdom
| | - Nicola Jones
- National Drug and Alcohol Research Centre (NDARC), University of New South Wales, Australia
| | | | - Matthew Bonn
- Canadian Association of People who Use Drugs (CAPUD), Canada
| | - Alice Wheeler
- Kirby Institute, University of New South Wales, Australia
| | - Jason Grebely
- Kirby Institute, University of New South Wales, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre (NDARC), University of New South Wales, Australia
| | - Matthew Hickman
- Population Health Sciences, University of Bristol, United Kingdom
| | - Andrew Hayward
- UCL Collaborative Centre for Inclusion Health, Department of Epidemiology and Public Health, University College London, United Kingdom
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre (NDARC), University of New South Wales, Australia
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Downing BC, Hickman M, Jones NR, Larney S, Sweeting MJ, Xu Y, Farrell M, Degenhardt L, Jones HE. Prevalence of opioid dependence in New South Wales, Australia, 2014-16: Indirect estimation from multiple data sources using a Bayesian approach. Addiction 2023; 118:1994-2006. [PMID: 37292044 DOI: 10.1111/add.16268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 05/09/2023] [Indexed: 06/10/2023]
Abstract
AIMS To estimate the prevalence of, and number of unobserved people with opioid dependence by sex and age group in New South Wales (NSW), Australia. DESIGN We applied a Bayesian statistical modelling approach to opioid agonist treatment records linked to adverse event rate data. We estimated prevalence from three types of adverse event separately: opioid mortality, opioid-poisoning hospitalizations and opioid-related charges. We extended the model and produced prevalence estimates from a 'multi-source' model based on all three types of adverse event data. SETTING, PARTICIPANTS AND MEASUREMENTS This study was conducted in NSW, Australia, 2014-16 using data from the Opioid Agonist Treatment and Safety (OATS) study, which included all people who had received treatment for opioid dependence in NSW. Aggregate data were obtained on numbers of adverse events in NSW. Rates of each adverse event type within the OATS cohort were modelled. Population data were provided by State and Commonwealth agencies. FINDINGS Prevalence of opioid dependence among those aged 15-64 years in 2016 was estimated to be 0.96% (95% credible interval [CrI] = 0.82%, 1.12%) from the mortality model, 0.75% (95% CrI = 0.70%, 0.83%) from hospitalizations, 0.95% (95% CrI = 0.90%, 0.99%) from charges and 0.92% (95% CrI = 0.88%, 0.96%) from the multi-source model. Of the estimated 46 460 (95% CrI = 44 680, 48 410) people with opioid dependence in 2016 from the multi-source model, approximately one-third (16 750, 95% CrI = 14 960, 18 690) had no record of opioid agonist treatment within the last 4 years. From the multi-source model, prevalence in 2016 was estimated to be 1.24% (95% CrI = 1.18%, 1.31%) in men aged 15-44, 1.22% (95% CrI = 1.14%, 1.31%) in men 45-64, 0.63% (95% CrI = 0.59%, 0.68%) in women aged 15-44 and 0.56% (95% CrI = 0.50%, 0.63%) in women aged 45-64. CONCLUSIONS A Bayesian statistical approach to estimate prevalence from multiple adverse event types simultaneously calculates that the estimated prevalence of opioid dependence in NSW, Australia in 2016 was 0.92%, higher than previous estimates.
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Affiliation(s)
- Beatrice C Downing
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicola R Jones
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Sarah Larney
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Montreal, Quebec, Canada
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Quebec, Canada
| | | | - Yixin Xu
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Hayley E Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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CERDÁ MAGDALENA, KRAWCZYK NOA, KEYES KATHERINE. The Future of the United States Overdose Crisis: Challenges and Opportunities. Milbank Q 2023; 101:478-506. [PMID: 36811204 PMCID: PMC10126987 DOI: 10.1111/1468-0009.12602] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
Policy Points People are dying at record numbers from overdose in the United States. Concerted action has led to a number of successes, including reduced inappropriate opioid prescribing and increased availability of opioid use disorder treatment and harm-reduction efforts, yet ongoing challenges include criminalization of drug use and regulatory and stigma barriers to expansion of treatment and harm-reduction services. Priorities for action include investing in evidence-based and compassionate policies and programs that address sources of opioid demand, decriminalizing drug use and drug paraphernalia, enacting policies to make medication for opioid use disorder more accessible, and promoting drug checking and safe drug supply.
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Affiliation(s)
- MAGDALENA CERDÁ
- Center for Opioid Epidemiology and PolicyNYU Grossman School of Medicine
| | - NOA KRAWCZYK
- Center for Opioid Epidemiology and PolicyNYU Grossman School of Medicine
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7
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Kiluk BD, Kleykamp BA, Comer SD, Griffiths RR, Huhn AS, Johnson MW, Kampman KM, Pravetoni M, Preston KL, Vandrey R, Bergeria CL, Bogenschutz MP, Brown RT, Dunn KE, Dworkin RH, Finan PH, Hendricks PS, Houtsmuller EJ, Kosten TR, Lee DC, Levin FR, McRae-Clark A, Raison CL, Rasmussen K, Turk DC, Weiss RD, Strain EC. Clinical Trial Design Challenges and Opportunities for Emerging Treatments for Opioid Use Disorder: A Review. JAMA Psychiatry 2023; 80:84-92. [PMID: 36449315 PMCID: PMC10297827 DOI: 10.1001/jamapsychiatry.2022.4020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Importance Novel treatments for opioid use disorder (OUD) are needed to address both the ongoing opioid epidemic and long-standing barriers to existing OUD treatments that target the endogenous μ-opioid receptor (MOR) system. The goal of this review is to highlight unique clinical trial design considerations for the study of emerging treatments for OUD that address targets beyond the MOR system. In November 2019, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the US Food and Drug Administration sponsored a meeting to discuss the current evidence regarding potential treatments for OUD, including cannabinoids, psychedelics, sedative-hypnotics, and immunotherapeutics, such as vaccines. Observations Consensus recommendations are presented regarding the most critical elements of trial design for the evaluation of novel OUD treatments, such as: (1) stage of treatment that will be targeted (eg, seeking treatment, early abstinence/detoxification, long-term recovery); (2) role of treatment (adjunctive with or independent of existing OUD treatments); (3) primary outcomes informed by patient preferences that assess opioid use (including changes in patterns of use), treatment retention, and/or global functioning and quality of life; and (4) adverse events, including the potential for opioid-related relapse or overdose, especially if the patient is not simultaneously taking maintenance MOR agonist or antagonist medications. Conclusions and Relevance Applying the recommendations provided here as well as considering input from people with lived experience in the design phase will accelerate the development, translation, and uptake of effective and safe therapeutics for individuals struggling with OUD.
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Affiliation(s)
- Brian D Kiluk
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Bethea A Kleykamp
- University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Sandra D Comer
- Division on Substance Use Disorders, New York State Psychiatric Institute, New York
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York
| | - Roland R Griffiths
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andrew S Huhn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthew W Johnson
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kyle M Kampman
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Marco Pravetoni
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Harborview Medical Center, Seattle
| | - Kenzie L Preston
- Clinical Pharmacology and Therapeutics Research Branch, National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Ryan Vandrey
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cecilia L Bergeria
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael P Bogenschutz
- Department of Psychiatry, NYU Grossman School of Medicine, New York University, New York
| | - Randall T Brown
- Department of Family Medicine and Community Health, University of Wisconsin-Madison School of Medicine and Public Health, Madison
| | - Kelly E Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robert H Dworkin
- University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Patrick H Finan
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Peter S Hendricks
- Department of Health Behavior, School of Public Health, University of Alabama at Birmingham
| | | | - Thomas R Kosten
- Baylor College of Medicine, Houston, Texas
- Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Dustin C Lee
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Frances R Levin
- Division on Substance Use Disorders, New York State Psychiatric Institute, New York
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Aimee McRae-Clark
- Department of Psychiatry, Medical University of South Carolina, Charleston
| | - Charles L Raison
- Department of Human Development and Family Studies, School of Human Ecology, University of Wisconsin-Madison
- Department of Psychiatry, School of Medicine and Public Health, University of Wisconsin-Madison
| | | | - Dennis C Turk
- University of Washington School of Medicine, Seattle
| | - Roger D Weiss
- Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Eric C Strain
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Padoei F, Mamsharifi P, Hazegh P, Boroumand H, Ostadmohammady F, Abbaszadeh-Mashkani S, Banafshe HR, Matini AH, Ghaderi A, Dehkohneh SG. The therapeutic effect of N-acetylcysteine as an add-on to methadone maintenance therapy medication in outpatients with substance use disorders: A randomized, double-blind, placebo-controlled clinical trial. Brain Behav 2023; 13:e2823. [PMID: 36448959 PMCID: PMC9847617 DOI: 10.1002/brb3.2823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 10/20/2022] [Accepted: 11/01/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Patients with substance use disorders (SUD) under methadone maintenance therapy (MMT) are susceptible to a number of complications (psychological and metabolic disorders). Evidence studies have shown the roles of the glutamatergic system in addiction. N-Acetylcysteine (NAC) enhances extracellular glutamate, and is effective in the treatment of neuropsychiatric disorders. We assessed oral NAC as an add-on to MMT medication for the treatment of SUD. METHODS In the current randomized, double-blind, placebo-controlled clinical trial, outpatients with SUD under MMT who were 18-60 years old received 2400 mg/day NAC (n = 30) or placebo (n = 30) for 12 weeks. Psychological status and metabolic biomarkers were assessed at baseline and the end of the trial. RESULTS Compared with the placebo group, NAC treatment resulted in a significant improvement in depression score (β -2.36; 95% CI, -3.97, -0.76; p = .005), and anxiety score (β -1.82; 95% CI, -3.19, -0.44; p = .01). Furthermore, NAC treatment resulted in a significant elevation in total antioxidant capacity levels (β 72.28 mmol/L; 95% CI, 11.36, 133.19; p = .02), total glutathione (GSH) levels (β 81.84 μmol/L; 95% CI, 15.40, 148.28; p = .01), and a significant reduction in high-sensitivity C-reactive protein levels (β -0.89 mg/L; 95% CI, -1.50, -0.28; p = .005), and homeostasis model of assessment-insulin resistance (β -0.33; 95% CI, -0.65, -0.009; p = .04), compared with the placebo group. CONCLUSION In the current study, improvement in depression and anxiety symptoms as well as some metabolic profiles with NAC treatment for 12 weeks in outpatients with SUD under MMT was detected.
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Affiliation(s)
- Fateme Padoei
- Student Research Committee, Kashan University of Medical Sciences, Kashan, Iran
| | - Peyman Mamsharifi
- Department of Psychology, Allameh Tabataba'i University, Tehran, Iran
| | - Pooya Hazegh
- Department of Psychiatry, Kashan University of Medical Sciences, Kashan, Iran
| | - Homa Boroumand
- Student Research Committee, Kashan University of Medical Sciences, Kashan, Iran
| | | | | | - Hamid Reza Banafshe
- Physiology Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Amir Hassan Matini
- Department of Clinical Pathology, Kashan University of Medical Sciences, Kashan, Iran
| | - Amir Ghaderi
- Department of Addiction studies, School of Medical, Kashan University of Medical Sciences, Kashan, Iran.,Clinical Research Development Unit-Matini/Kargarnejad Hospital, Kashan University of Medical Sciences, Kashan, Iran
| | - Somayeh Ghadami Dehkohneh
- Department of Pharmacy, Acharya BM ready college of Pharmacy, Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka, India
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9
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Andraka-Christou B, Totaram R, Nguyen TD. Comprehensive analysis of discharge reasons from methadone outpatient treatment programs. Am J Addict 2022; 31:508-516. [PMID: 35996855 DOI: 10.1111/ajad.13326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/17/2022] [Accepted: 08/01/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Methadone treatment (MT) for opioid use disorder is only available in opioid treatment programs (OTPs) in the United States, with retention predictive of positive health outcomes. OTP discharge reason information is needed to develop interventions for facilitating MT retention. We sought to identify discharge reason frequencies and associations between discharge reasons and facility/county-level characteristics. METHODS We examined annual OTP discharge reasons for all Florida OTPs from 2014 to 2017 (n = 44,774 discharges). We used multinomial logistic regression analysis to examine associations between patients' discharge reasons and (1) facility-level characteristics (e.g., size, funding type) and (2) county-level characteristics (e.g., race/ethnicity, overdose rates). RESULTS Lost contact was the most common discharge reason (29%). Only 11% of patients were discharged for treatment completion, with the proportion one-third as low in privately versus publicly-funded OTPs (p < .001). Privately-funded OTPs had a patient share self-terminating treatment against medical advice about 3.5 times higher than publicly-funded OTPs. Inability to pay accounted for 7% of OTP discharges. Noncompliant discharges represented 6% and were more common in counties with larger proportions of Black residents (p < .01). Counties with higher drug overdose rates had significantly more discharges for noncompliance or self-terminating against medical advice (p < .01 and p < .05). DISCUSSION AND CONCLUSIONS Statewide differences in discharge reasons exist between publicly and privately-funded OTPs, possibly reflecting differences in funding incentives and state oversight. State agencies should develop consistent approaches for collecting/reporting discharge reasons. SCIENTIFIC SIGNIFICANCE Our study is the first to examine the relationship between OTP funding type and discharge reasons.
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Affiliation(s)
- Barbara Andraka-Christou
- School of Global Health Management & Informatics, University of Central Florida, Orlando, Florida, USA.,Department of Internal Medicine, University of Central Florida, Orlando, Florida, USA
| | - Rachel Totaram
- School of Global Health Management & Informatics, University of Central Florida, Orlando, Florida, USA
| | - Thuy D Nguyen
- Department of Health Management & Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
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Morin KA, Dabous JR, Vojtesek F, Marsh D. Evaluating the association between urine drug screening frequency and retention in opioid agonist treatment in Ontario, Canada: a retrospective cohort study. BMJ Open 2022; 12:e060857. [PMID: 36223960 PMCID: PMC9562722 DOI: 10.1136/bmjopen-2022-060857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE The objective of this study was to evaluate how urine drug screening (UDS) frequency is associated with retention in opioid agonist treatment (OAT). METHODS Data for this retrospective cohort study of 55 921 adults in OAT in Ontario, Canada, were derived from administrative sources between 1 January 2011 and 31 December 2015. All patient information was linked anonymously across databases using encrypted health card numbers. Descriptive statistics were calculated for comparing UDS frequency groups using standardised differences (d) where d less than 10% indicated a statistically significant difference. A logistic regression model was then used to calculate ORs adjusting for baseline covariates, including sex, age, location of residence, income quintile, mental disorders, HIV status and deep tissue infections. RESULTS Over 70% of the cohort had four or more UDS tests per month (weekly or more UDS). Significant associations were observed between UDS frequency and 1-year treatment retention in OAT biweekly (adjusted OR (aOR)=3.20, 95% CI 2.75 to 3.75); weekly UDS (aOR=6.86, 95% CI 5.88 to 8.00) and more than weekly (aOR=8.03, 95% CI 6.87 to 9.38) using the monthly or less groups as the reference. CONCLUSION This study identified an association between weekly UDS and 1-year treatment retention in OAT. There is an active discussion within Canada about the utility of UDS. The lack of evidence for the impact of UDS on retention has left it open to some to argue they simply provide a barrier to patient engagement. Therefore, it is timely of this study to demonstrate that more frequent urine testing is not associated with a reduction in treatment retention.
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Affiliation(s)
- Kristen A Morin
- ICES North, Sudbury, Ontario, Canada
- Health Sciences North Research Institute, Sudbury, Ontario, Canada
- Northern Ontario School of Medicine-East Campus, Sudbury, Ontario, Canada
| | - John R Dabous
- Northern Ontario School of Medicine-East Campus, Sudbury, Ontario, Canada
| | - Frank Vojtesek
- Northern Ontario School of Medicine-East Campus, Sudbury, Ontario, Canada
| | - David Marsh
- ICES North, Sudbury, Ontario, Canada
- Northern Ontario School of Medicine-East Campus, Sudbury, Ontario, Canada
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11
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Calcaterra SL, Martin M, Bottner R, Englander H, Weinstein Z, Weimer MB, Lambert E, Herzig SJ. Management of opioid use disorder and associated conditions among hospitalized adults: A Consensus Statement from the Society of Hospital Medicine. J Hosp Med 2022; 17:744-756. [PMID: 35880813 PMCID: PMC9474708 DOI: 10.1002/jhm.12893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/25/2022] [Accepted: 05/29/2022] [Indexed: 01/14/2023]
Abstract
Hospital-based clinicians frequently care for patients with opioid withdrawal or opioid use disorder (OUD) and are well-positioned to identify and initiate treatment for these patients. With rising numbers of hospitalizations related to opioid use and opioid-related overdose, the Society of Hospital Medicine convened a working group to develop a Consensus Statement on the management of OUD and associated conditions among hospitalized adults. The guidance statement is intended for clinicians practicing medicine in the inpatient setting (e.g., hospitalists, primary care physicians, family physicians, advanced practice nurses, and physician assistants) and is intended to apply to hospitalized adults at risk for, or diagnosed with, OUD. To develop the Consensus Statement, the working group conducted a systematic review of relevant guidelines and composed a draft statement based on extracted recommendations. Next, the working group obtained feedback on the draft statement from external experts in addiction medicine, SHM members, professional societies, harm reduction organizations and advocacy groups, and peer reviewers. The iterative development process resulted in a final Consensus Statement consisting of 18 recommendations covering the following topics: (1) identification and treatment of OUD and opioid withdrawal, (2) perioperative and acute pain management in patients with OUD, and (3) methods to optimize care transitions at hospital discharge for patients with OUD. Most recommendations in the Consensus Statement were derived from guidelines based on observational studies and expert consensus. Due to the lack of rigorous evidence supporting key aspects of OUD-related care, the working group identified important issues necessitating future research and exploration.
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Affiliation(s)
- Susan L. Calcaterra
- Department of Medicine, Division of General Internal Medicine and Division of Hospital Medicine, University of Colorado, Aurora, CO, USA
| | - Marlene Martin
- Department of Medicine, Division of Hospital Medicine, University of California San Francisco and San Francisco General Hospital, San Francisco, CA, USA
| | - Richard Bottner
- Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, TX, USA
| | - Honora Englander
- Department of Medicine, Section of Addiction Medicine and Division of Hospital Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Zoe Weinstein
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | | | - Eugene Lambert
- Harvard Medical School and Massachusetts General Hospital, Department of Medicine, Division of General Internal Medicine, Boston, MA, USA
| | - Shoshana J. Herzig
- Harvard Medical School and Massachusetts General Hospital, Department of Medicine, Division of General Internal Medicine, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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12
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Brothers TD, Lewer D, Jones N, Colledge-Frisby S, Farrell M, Hickman M, Webster D, Hayward A, Degenhardt L. Opioid agonist treatment and risk of death or rehospitalization following injection drug use-associated bacterial and fungal infections: A cohort study in New South Wales, Australia. PLoS Med 2022; 19:e1004049. [PMID: 35853024 PMCID: PMC9295981 DOI: 10.1371/journal.pmed.1004049] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 06/12/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Injecting-related bacterial and fungal infections are associated with significant morbidity and mortality among people who inject drugs (PWID), and they are increasing in incidence. Following hospitalization with an injecting-related infection, use of opioid agonist treatment (OAT; methadone or buprenorphine) may be associated with reduced risk of death or rehospitalization with an injecting-related infection. METHODS AND FINDINGS Data came from the Opioid Agonist Treatment Safety (OATS) study, an administrative linkage cohort including all people in New South Wales, Australia, who accessed OAT between July 1, 2001 and June 28, 2018. Included participants survived a hospitalization with injecting-related infections (i.e., skin and soft-tissue infection, sepsis/bacteremia, endocarditis, osteomyelitis, septic arthritis, or epidural/brain abscess). Outcomes were all-cause death and rehospitalization for injecting-related infections. OAT exposure was classified as time varying by days on or off treatment, following hospital discharge. We used separate Cox proportional hazards models to assess associations between each outcome and OAT exposure. The study included 8,943 participants (mean age 39 years, standard deviation [SD] 11 years; 34% women). The most common infections during participants' index hospitalizations were skin and soft tissue (7,021; 79%), sepsis/bacteremia (1,207; 14%), and endocarditis (431; 5%). During median 6.56 years follow-up, 1,481 (17%) participants died; use of OAT was associated with lower hazard of death (adjusted hazard ratio [aHR] 0.63, 95% confidence interval [CI] 0.57 to 0.70). During median 3.41 years follow-up, 3,653 (41%) were rehospitalized for injecting-related infections; use of OAT was associated with lower hazard of these rehospitalizations (aHR 0.89, 95% CI 0.84 to 0.96). Study limitations include the use of routinely collected administrative data, which lacks information on other risk factors for injecting-related infections including injecting practices, injection stimulant use, housing status, and access to harm reduction services (e.g., needle exchange and supervised injecting sites); we also lacked information on OAT medication dosages. CONCLUSIONS Following hospitalizations with injection drug use-associated bacterial and fungal infections, use of OAT is associated with lower risks of death and recurrent injecting-related infections among people with opioid use disorder.
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Affiliation(s)
- Thomas D. Brothers
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, Australia
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
- Department of Medicine, Dalhousie University, Halifax, Canada
| | - Dan Lewer
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, Australia
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
| | - Nicola Jones
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, Australia
| | | | - Michael Farrell
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, Australia
| | - Matthew Hickman
- Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Duncan Webster
- Department of Medicine, Dalhousie University, Halifax, Canada
- Division of Infectious Diseases, Saint John Regional Hospital, Saint John, Canada
| | - Andrew Hayward
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, Australia
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13
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Jain R, Sarkar S, Saifi N, Ghosh S. Urinalysis based assessment of compliance and drug use patterns in patients prescribed tramadol: A cross-sectional study from a tertiary care centre. Asian J Psychiatr 2022; 71:103080. [PMID: 35305452 DOI: 10.1016/j.ajp.2022.103080] [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: 02/20/2022] [Accepted: 03/09/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Strict adherence to pharmacological dosage regimens is a prerequisite to the success of most treatments, particularly for patients in drug abuse programs. The compliance of tramadol, an atypical non-scheduled narcotic analgesic, using objective method has not been adequately studied in an Indian setting. AIM To evaluate the compliance and pattern of drug use among opioid-dependent subjects prescribed tramadol based on urinalysis. METHOD Fifty male opioid-dependent patients (ICD 10), seeking treatment at a tertiary de-addiction treatment centre of North India on tramadol prescription for atleast past four weeks were included. Self-reported substance use was recorded using semi-structured proforma. Ten ml of urine was collected for the assessment of compliance of tramadol of other substance use (morphine, buprenorphine, dextropropoxyphene, pentazocine, cannabis, benzodiazepines, pheniramine). All these drugs were analyzed using the immunoassay-based Cassette test and Gas Chromatography in human urine. RESULT Mean age of the participants was 42.8 years and the mean duration of opioid use was 15.9years. The urine specimen of all subjects tested positive for tramadol. Urinalysis revealed benzodiazepines, cannabis, and pheniramine to be the most common substances of use in this population. It was seen that agreement of self-reporting and urine test results was good for morphine (κ = 0.558) and cannabis (κ = 0.312) and was poor for buprenorphine, pentazocine, and pheniramine. CONCLUSION The study demonstrates the continued use of several illicit or non-prescribed medications in a medication-assisted opioid treatment population. The results affirm the reliability of urinalysis as an adjunct for testing compliance in such a population.
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Affiliation(s)
- Raka Jain
- National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi 110029, India.
| | - Siddharth Sarkar
- National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi 110029, India.
| | - Nizamuddin Saifi
- National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi 110029, India.
| | - Shayani Ghosh
- National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi 110029, India.
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Simon C, Vincent L, Coulter A, Salazar Z, Voyles N, Roberts L, Frank D, Brothers S. The Methadone Manifesto: Treatment Experiences and Policy Recommendations From Methadone Patient Activists. Am J Public Health 2022; 112:S117-S122. [PMID: 35349312 PMCID: PMC8965191 DOI: 10.2105/ajph.2021.306665] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Caty Simon
- All of the authors are with the Urban Survivors Union Methadone Advocacy and Reform Working Group. Caty Simon and Lindsay Roberts are with Whose Corner Is It Anyway, Holyoke, MA. Louise Vincent and Zach Salazar are with North Carolina Survivors Union, Greensboro. Abby Coulter is with Medication Assisted Treatment Support & Awareness, Morgantown, WV. Nick Voyles is with the Indiana Recovery Alliance, Bloomington. David Frank is with the School of Global Public Health, New York University, New York, NY. Sarah Brothers is with the Department of Sociology and School of Public Policy, Pennsylvania State University, University Park
| | - Louise Vincent
- All of the authors are with the Urban Survivors Union Methadone Advocacy and Reform Working Group. Caty Simon and Lindsay Roberts are with Whose Corner Is It Anyway, Holyoke, MA. Louise Vincent and Zach Salazar are with North Carolina Survivors Union, Greensboro. Abby Coulter is with Medication Assisted Treatment Support & Awareness, Morgantown, WV. Nick Voyles is with the Indiana Recovery Alliance, Bloomington. David Frank is with the School of Global Public Health, New York University, New York, NY. Sarah Brothers is with the Department of Sociology and School of Public Policy, Pennsylvania State University, University Park
| | - Abby Coulter
- All of the authors are with the Urban Survivors Union Methadone Advocacy and Reform Working Group. Caty Simon and Lindsay Roberts are with Whose Corner Is It Anyway, Holyoke, MA. Louise Vincent and Zach Salazar are with North Carolina Survivors Union, Greensboro. Abby Coulter is with Medication Assisted Treatment Support & Awareness, Morgantown, WV. Nick Voyles is with the Indiana Recovery Alliance, Bloomington. David Frank is with the School of Global Public Health, New York University, New York, NY. Sarah Brothers is with the Department of Sociology and School of Public Policy, Pennsylvania State University, University Park
| | - Zach Salazar
- All of the authors are with the Urban Survivors Union Methadone Advocacy and Reform Working Group. Caty Simon and Lindsay Roberts are with Whose Corner Is It Anyway, Holyoke, MA. Louise Vincent and Zach Salazar are with North Carolina Survivors Union, Greensboro. Abby Coulter is with Medication Assisted Treatment Support & Awareness, Morgantown, WV. Nick Voyles is with the Indiana Recovery Alliance, Bloomington. David Frank is with the School of Global Public Health, New York University, New York, NY. Sarah Brothers is with the Department of Sociology and School of Public Policy, Pennsylvania State University, University Park
| | - Nick Voyles
- All of the authors are with the Urban Survivors Union Methadone Advocacy and Reform Working Group. Caty Simon and Lindsay Roberts are with Whose Corner Is It Anyway, Holyoke, MA. Louise Vincent and Zach Salazar are with North Carolina Survivors Union, Greensboro. Abby Coulter is with Medication Assisted Treatment Support & Awareness, Morgantown, WV. Nick Voyles is with the Indiana Recovery Alliance, Bloomington. David Frank is with the School of Global Public Health, New York University, New York, NY. Sarah Brothers is with the Department of Sociology and School of Public Policy, Pennsylvania State University, University Park
| | - Lindsay Roberts
- All of the authors are with the Urban Survivors Union Methadone Advocacy and Reform Working Group. Caty Simon and Lindsay Roberts are with Whose Corner Is It Anyway, Holyoke, MA. Louise Vincent and Zach Salazar are with North Carolina Survivors Union, Greensboro. Abby Coulter is with Medication Assisted Treatment Support & Awareness, Morgantown, WV. Nick Voyles is with the Indiana Recovery Alliance, Bloomington. David Frank is with the School of Global Public Health, New York University, New York, NY. Sarah Brothers is with the Department of Sociology and School of Public Policy, Pennsylvania State University, University Park
| | - David Frank
- All of the authors are with the Urban Survivors Union Methadone Advocacy and Reform Working Group. Caty Simon and Lindsay Roberts are with Whose Corner Is It Anyway, Holyoke, MA. Louise Vincent and Zach Salazar are with North Carolina Survivors Union, Greensboro. Abby Coulter is with Medication Assisted Treatment Support & Awareness, Morgantown, WV. Nick Voyles is with the Indiana Recovery Alliance, Bloomington. David Frank is with the School of Global Public Health, New York University, New York, NY. Sarah Brothers is with the Department of Sociology and School of Public Policy, Pennsylvania State University, University Park
| | - Sarah Brothers
- All of the authors are with the Urban Survivors Union Methadone Advocacy and Reform Working Group. Caty Simon and Lindsay Roberts are with Whose Corner Is It Anyway, Holyoke, MA. Louise Vincent and Zach Salazar are with North Carolina Survivors Union, Greensboro. Abby Coulter is with Medication Assisted Treatment Support & Awareness, Morgantown, WV. Nick Voyles is with the Indiana Recovery Alliance, Bloomington. David Frank is with the School of Global Public Health, New York University, New York, NY. Sarah Brothers is with the Department of Sociology and School of Public Policy, Pennsylvania State University, University Park
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15
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Molavi N, Rasouli-Azad M, Mirzaei H, Matini AH, Banafshe HR, Valiollahzadeh M, Hassanzadeh M, Saghazade AR, Abbaszadeh-Mashkani S, Mamsharifi P, Ghaderi A. The Effects of Probiotic Supplementation on Opioid-Related Disorder in Patients under Methadone Maintenance Treatment Programs. Int J Clin Pract 2022; 2022:1206914. [PMID: 35685534 PMCID: PMC9159114 DOI: 10.1155/2022/1206914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 03/11/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Patients under methadone maintenance treatment programs (MMTPs) are susceptible to numerous complications (e.g., mental and metabolic disorders). This study evaluated the effects of probiotics on clinical symptoms, biomarkers of oxidative stress, inflammation, insulin resistance, and serum lipid content in patients receiving MMTPs. MATERIALS AND METHODS A randomized, double-blind, placebo-controlled trial was conducted among 70 patients receiving MMTPs to receive either 1.8 × 109 CFU/day probiotics (n = 35) or placebo (n = 35) for 12 weeks. Clinical symptoms and metabolic profiles were measured before and after the intervention in patients receiving MMTPs. RESULTS Compared with the placebo group, probiotic supplementation resulted in a significant improvement in the severity of depression (P < 0.05). In addition, probiotic administration significantly decreased fasting plasma glucose (FPG), total cholesterol, and low-density lipoprotein cholesterol (LDL cholesterol) (P < 0.05). Furthermore, probiotics resulted in a significant reduction in high-sensitivity C-reactive protein (hs-CRP) and a significant elevation in total antioxidant capacity (TAC) and total glutathione (GSH) levels (P < 0.05). CONCLUSION Treatment with probiotics for 12 weeks to patients receiving MMTPs had beneficial effects on symptoms of depression, as well as several metabolic profiles. Clinical Trial Registration: this study was registered in the Iranian website (https://www.irct.ir) for clinical trials registration (https://fa.irct.ir/trial/46363/IRCT20170420033551N9). The registration date is March 22, 2020.
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Affiliation(s)
- Nader Molavi
- Department of Addiction Studies, School of Medical, Kashan University of Medical Sciences, Kashan, Iran
| | - Morad Rasouli-Azad
- International Center for Comparative Criminology, University of Montreal, Montreal, Canada
| | - Hamed Mirzaei
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran
| | - Amir Hassan Matini
- Department of Clinical Pathology, Kashan University of Medical Sciences, Kashan, Iran
| | - Hamid Reza Banafshe
- Department of Addiction Studies, School of Medical, Kashan University of Medical Sciences, Kashan, Iran
- Physiology Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | | | - Majid Hassanzadeh
- Department of Addiction Studies, School of Medical, Kashan University of Medical Sciences, Kashan, Iran
| | - Ahmad Reza Saghazade
- Student Research Committee, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Samira Abbaszadeh-Mashkani
- Trauma Nursing Research Center, Faculty of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan, Iran
| | - Peyman Mamsharifi
- Department of Psychology, Allameh Tabataba'i University, Tehran, Iran
| | - Amir Ghaderi
- Department of Addiction Studies, School of Medical, Kashan University of Medical Sciences, Kashan, Iran
- Clinical Research Development Unit-Matini/Kargarnejad Hospital, Kashan University of Medical Sciences, Kashan, Iran
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Ching JH, Owens DK, Trafton JA, Goldhaber-Fiebert JD, Salomon JA. Impact of treatment duration on mortality among Veterans with opioid use disorder in the United States Veterans Health Administration. Addiction 2021; 116:3494-3503. [PMID: 33999485 PMCID: PMC8578188 DOI: 10.1111/add.15574] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/18/2021] [Accepted: 05/05/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS While long-term medication-assisted treatment (MAT) using methadone or buprenorphine is associated with significantly lower all-cause mortality for individuals with opioid use disorder (OUD), periods of initiating or discontinuing treatment are associated with higher mortality risks relative to stable treatment. This study aimed to identify the OUD treatment durations necessary for the elevated mortality risks during treatment transitions to be balanced by reductions in mortality while receiving treatment. DESIGN Simulation model based on a compartmental model of OUD diagnosis, MAT receipt and all-cause mortality among Veterans with OUD in the United States Veterans Health Administration (VA) in 2017-2018. We simulated methadone and buprenorphine treatments of varying durations using parameters obtained through calibration and published meta-analyses of studies from North America, Europe and Australia. SETTING United States. PARTICIPANTS Simulated cohorts of 10 000 individuals with OUD. MEASUREMENTS All-cause mortality over 12 months. FINDINGS Receiving methadone for 4 months or longer or buprenorphine for 2 months or longer resulted in 54 [95% confidence interval (CI) = 5-90] and 65 (95% CI = 21-89) fewer deaths relative to not receiving MAT for the same duration, using VA-specific mortality rates. We estimated shorter treatment durations necessary to achieve net mortality benefits of 2 months or longer for methadone and 1 month or longer for buprenorphine, using non-VA population literature estimates. Sensitivity analyses demonstrated that necessary treatment durations increased more with smaller mortality reductions on treatment than with larger relative risks during treatment transitions. CONCLUSIONS Short periods (< 6 months) of treatment with either methadone or buprenorphine are likely to yield net mortality benefits for people with opioid use disorder relative to receiving no medications, despite periods of elevated all-cause mortality risk during transitions into and out of treatment. Retaining people with opioid use disorder in treatment longer can increase these benefits.
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Affiliation(s)
- Jack H. Ching
- Center for Health Policy and Center for Primary Care & Outcomes Research, Stanford University School of Medicine, Stanford, CA,Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, VA Palo Alto Health Care System, Menlo Park, CA
| | - Douglas K. Owens
- Center for Health Policy and Center for Primary Care & Outcomes Research, Stanford University School of Medicine, Stanford, CA,VA Palo Alto Health Care System, Palo Alto, CA
| | - Jodie A. Trafton
- Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, VA Palo Alto Health Care System, Menlo Park, CA
| | - Jeremy D. Goldhaber-Fiebert
- Center for Health Policy and Center for Primary Care & Outcomes Research, Stanford University School of Medicine, Stanford, CA
| | - Joshua A. Salomon
- Center for Health Policy and Center for Primary Care & Outcomes Research, Stanford University School of Medicine, Stanford, CA
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Brenna IH, Marciuch A, Birkeland B, Veseth M, Røstad B, Løberg EM, Solli KK, Tanum L, Weimand B. 'Not at all what I had expected': Discontinuing treatment with extended-release naltrexone (XR-NTX): A qualitative study. J Subst Abuse Treat 2021; 136:108667. [PMID: 34865937 DOI: 10.1016/j.jsat.2021.108667] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/08/2021] [Accepted: 11/19/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Extended-release naltrexone (XR-NTX), an opioid antagonist, has demonstrated equal treatment outcomes, in terms of safety, opioid use, and retention, to the recommended OMT medication buprenorphine. However, premature discontinuation of XR-NTX treatment is still common and poorly understood. Research on patient experiences of XR-NTX treatment is limited. We sought to explore participants' experiences with discontinuation of treatment with XR-NTX, particularly motivation for XR-NTX, experiences of initiation and treatment, and rationale for leaving treatment. METHODS We conducted qualitative, semi-structured interviews with participants from a clinical trial of XR-NTX. The study participants (N = 13) included seven women and six men with opioid dependence, who had received a minimum of one and maximum of four injections of XR-NTX. The study team analyzed transcribed interviews, employing thematic analysis with a critical realist approach. FINDINGS The research team identified three themes, and we present them as a chronological narrative: theme 1: Entering treatment - I thought I knew what I was going into; theme 2: Life with XR-NTX - I had something in me that I didn't want; and theme 3: Leaving treatment - I want to go somewhere in life. Patients' unfulfilled expectations of how XR-NTX would lead to a better life were central to decisions about discontinuation, including unexpected physical, emotional, or mental reactions as well as a lack of expected effects, notably some described an opioid effect from buprenorphine. A few participants ended treatment because they had reached their treatment goal, but most expressed disappointment about not achieving this goal. Some also expressed renewed acceptance of OMT. The participants' motivation for abstinence from illegal substances generally remained. CONCLUSION Our findings emphasize that a dynamic understanding of discontinuation of treatment is necessary to achieve a long-term approach to recovery: the field should understand discontinuation as a feature of typical treatment trajectories, and discontinuation can be followed by re-initiation of treatment.
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Affiliation(s)
- Ida Halvorsen Brenna
- Department of Addiction Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Psychology, Faculty of Psychology, University of Bergen, Bergen, Norway.
| | - Anne Marciuch
- Department of Research and Development in Mental Health, Akershus University Hospital, Lørenskog, Norway; Department of Medicine, University of Oslo, Oslo, Norway
| | - Bente Birkeland
- Department of Psychosocial Health, Faculty of Health and Sports Science, University of Agder, Kristiansand, Norway
| | - Marius Veseth
- Department of Clinical Psychology, Faculty of Psychology, University of Bergen, Bergen, Norway
| | - Bente Røstad
- RIO-a Norwegian users' association in the field of alcohol and drugs, Oslo, Norway
| | - Else-Marie Løberg
- Department of Addiction Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Psychology, Faculty of Psychology, University of Bergen, Bergen, Norway; Department of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Kristin Klemmetsby Solli
- Department of Research and Development in Mental Health, Akershus University Hospital, Lørenskog, Norway; Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway; Vestfold Hospital Trust, Toensberg, Norway
| | - Lars Tanum
- Department of Research and Development in Mental Health, Akershus University Hospital, Lørenskog, Norway; Faculty for Health Science, Oslo Metropolitan University, Oslo, Norway
| | - Bente Weimand
- Department of Research and Development in Mental Health, Akershus University Hospital, Lørenskog, Norway; Department of Health, Social and Welfare Studies, Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
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18
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Soyka M. Transition From Full Mu Opioid Agonists to Buprenorphine in Opioid Dependent Patients-A Critical Review. Front Pharmacol 2021; 12:718811. [PMID: 34887748 PMCID: PMC8650116 DOI: 10.3389/fphar.2021.718811] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 10/05/2021] [Indexed: 12/28/2022] Open
Abstract
Methadone, a full opioid agonist at the mu-, kappa-, and delta-receptor, and buprenorphine, a partial agonist at the mu receptor, are first-line medications in opioid maintenance treatment. Transition from methadone to buprenorphine may precipitate withdrawal, and no accepted algorithm for this procedure has been developed. Current treatment strategies recommend transfer from methadone to buprenorphine predominantly in patients at low doses of methadone (30-40 mg/day). There are some reports indicating that transition from higher doses of methadone may be possible. A number of dosing strategies have been proposed to soften withdrawal symptoms and facilitate transfer including use of other opioids or medications and especially microdosing techniques for buprenorphine. The case series and studies available thus far are reviewed.
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Affiliation(s)
- Michael Soyka
- Psychiatric Hospital, University of Munich, Munich, Germany
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Lynn E, Cousins G, Lyons S, Bennett KE. Trends in drug poisoning deaths, by sex, in Ireland: a repeated cross-sectional study from 2004 to 2017. BMJ Open 2021; 11:e048000. [PMID: 34479934 PMCID: PMC8420717 DOI: 10.1136/bmjopen-2020-048000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 08/16/2021] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To examine sex differences in age-standardised rates (ASR) of overall and drug-specific drug poisoning deaths in Ireland between 2004 and 2017. DESIGN Repeated cross-sectional study. SETTING Drug poisoning deaths in Ireland. PARTICIPANTS National Drug-Related Deaths Index and pharmacy claims database (Primary Care Reimbursement Service-General Medical Services) data from 2004 to 2017. OUTCOME MEASURES The primary outcome was trends in drug poisoning death rates by sex. The secondary outcomes were trends in drug poisoning death rates involving (1) any CNS (Central Nervous System) depressants, (2) ≥2 CNS depressants and (3) specific drugs/drug classes (eg, prescription opioids, benzodiazepines, antidepressants, alcohol, cocaine and heroin) by sex. Joinpoint regression was used to examine trends, stratified by sex, in the ASR of drug poisoning deaths (2004-2017), change points over time and average annual percentage changes (AAPCs) with 95% CI. RESULTS Increased ASR for all drug poisoning deaths from 6.86 (95% CI 6.01 to 7.72) per 100 000 in 2004 to 8.08 (95% CI 7.25 to 8.91) per 100 000 in 2017 was mainly driven by increasing deaths among men (AAPC 2.6%, 95% CI 0.2 to 5.1), with no significant change observed among women. Deaths involving ≥2 CNS depressants increased for both men (AAPC 5.6%, 95% CI 2.4 to 8.8) and women (AAPC 4.0%, 95% CI 1.1 to 6.9). Drugs with the highest significant AAPC increases for men were cocaine (7.7%, 95% CI 2.2 to 13.6), benzodiazepines (7.2%, 95% CI 2.9 to 11.6), antidepressants (6.1%, 95% CI 2.4 to 10.0) and prescription opioids (3.5%, 95% CI 1.6 to 5.5). For women, the highest AAPC was for antidepressants (4.2%, 95% CI 0.2 to 8.3), benzodiazepines (3.3%, 95% CI 0.1 to 6.5) and prescription opioids (3.0%, 95% CI 0.7 to 5.3). CONCLUSION Drugs implicated in drug poisoning deaths vary by sex. Policy response should include prescription monitoring programmes and practical harm reduction information on polydrug use, especially CNS depressant drugs.
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Affiliation(s)
- Ena Lynn
- National Health Information Systems, Health Research Board, Dublin 2, Ireland
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Gráinne Cousins
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Suzi Lyons
- National Health Information Systems, Health Research Board, Dublin 2, Ireland
| | - Kathleen E Bennett
- Data Science Centre, Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
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20
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Santo T, Clark B, Hickman M, Grebely J, Campbell G, Sordo L, Chen A, Tran LT, Bharat C, Padmanathan P, Cousins G, Dupouy J, Kelty E, Muga R, Nosyk B, Min J, Pavarin R, Farrell M, Degenhardt L. Association of Opioid Agonist Treatment With All-Cause Mortality and Specific Causes of Death Among People With Opioid Dependence: A Systematic Review and Meta-analysis. JAMA Psychiatry 2021; 78:979-993. [PMID: 34076676 PMCID: PMC8173472 DOI: 10.1001/jamapsychiatry.2021.0976] [Citation(s) in RCA: 243] [Impact Index Per Article: 81.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/01/2021] [Indexed: 12/11/2022]
Abstract
Importance Mortality among people with opioid dependence is higher than that of the general population. Opioid agonist treatment (OAT) is an effective treatment for opioid dependence; however, there has not yet been a systematic review on the relationship between OAT and specific causes of mortality. Objective To estimate the association of time receiving OAT with mortality. Data Sources The Embase, MEDLINE, and PsycINFO databases were searched through February 18, 2020, including clinical trial registries and previous Cochrane reviews. Study Selection All observational studies that collected data on all-cause or cause-specific mortality among people with opioid dependence while receiving and not receiving OAT were included. Randomized clinical trials (RCTs) were also included. Data Extraction and Synthesis This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Data on study, participant, and treatment characteristics were extracted; person-years, all-cause mortality, and cause-specific mortality were calculated. Crude mortality rates and rate ratios (RRs) were pooled using random-effects meta-analyses. Main Outcomes and Measures Overall all-cause and cause-specific mortality both by setting and by participant characteristics. Methadone and buprenorphine OAT were evaluated specifically. Results Fifteen RCTs including 3852 participants and 36 primary cohort studies including 749 634 participants were analyzed. Among the cohort studies, the rate of all-cause mortality during OAT was more than half of the rate seen during time out of OAT (RR, 0.47; 95% CI, 0.42-0.53). This association was consistent regardless of patient sex, age, geographic location, HIV status, and hepatitis C virus status and whether drugs were taken through injection. Associations were not different for methadone (RR, 0.47; 95% CI, 0.41-0.54) vs buprenorphine (RR, 0.34; 95% CI, 0.26-0.45). There was lower risk of suicide (RR, 0.48; 95% CI, 0.37-0.61), cancer (RR, 0.72; 95% CI, 0.52-0.98), drug-related (RR, 0.41; 95% CI, 0.33-0.52), alcohol-related (RR, 0.59; 95% CI, 0.49-0.72), and cardiovascular-related (RR, 0.69; 95% CI, 0.60-0.79) mortality during OAT. In the first 4 weeks of methadone treatment, rates of all-cause mortality and drug-related poisoning were almost double the rates during the remainder of OAT (RR, 2.01; 95% CI, 1.55-5.09) but not for buprenorphine (RR, 0.58; 95% CI, 0.18-1.85). All-cause mortality was 6 times higher in the 4 weeks after OAT cessation (RR, 6.01; 95% CI, 4.32-8.36), remaining double the rate for the remainder of time not receiving OAT (RR, 1.81; 95% CI, 1.50-2.18). Opioid agonist treatment was associated with a lower risk of mortality during incarceration (RR, 0.06; 95% CI, 0.01-0.46) and after release from incarceration (RR, 0.09; 95% CI, 0.02-0.56). Conclusions and Relevance This systematic review and meta-analysis found that OAT was associated with lower rates of mortality. However, access to OAT remains limited, and coverage of OAT remains low. Work to improve access globally may have important population-level benefits.
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Affiliation(s)
- Thomas Santo
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Sydney, Australia
| | - Brodie Clark
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Sydney, Australia
| | - Matt Hickman
- Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Jason Grebely
- Kirby Institute, University of New South Wales, Sydney, Sydney, Australia
| | - Gabrielle Campbell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Sydney, Australia
- University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
| | - Luis Sordo
- Consortium for Biomedical Research in Epidemiology and Public Health, Madrid, Spain
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Aileen Chen
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Sydney, Australia
- Clinical Research Unit for Anxiety and Depression, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Lucy Thi Tran
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Sydney, Australia
| | - Chrianna Bharat
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Sydney, Australia
| | | | - Grainne Cousins
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Julie Dupouy
- University Department of General Medicine, University of Toulouse, Faculty of Medicine, Toulouse, France
- Inserm UMR1027, University of Toulouse III, Faculty of Medicine, Toulouse, France
| | - Erin Kelty
- The School of Population & Global Health, The University of Western Australia, Perth, Australia
| | - Roberto Muga
- Department of Internal Medicine, Germans Trias i Pujol-IGTP University Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Bohdan Nosyk
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Jeong Min
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Raimondo Pavarin
- Epidemiological Monitoring Center on Addiction, Azienda Unità Sanitaria Locale Bologna, Mental Health Dipartimento Salute Mentale – Dipendenze Patologiche, Bologna, Italy
- Italian Society on Addiction, Milan, Italy
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Sydney, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Sydney, Australia
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21
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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.
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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.
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22
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Krawczyk N, Williams AR, Saloner B, Cerdá M. Who stays in medication treatment for opioid use disorder? A national study of outpatient specialty treatment settings. J Subst Abuse Treat 2021; 126:108329. [PMID: 34116820 PMCID: PMC8197774 DOI: 10.1016/j.jsat.2021.108329] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/31/2020] [Accepted: 02/09/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Maintenance treatments with medications for opioid use disorder (MOUD) are highly effective at reducing overdose risk while patients remain in care. However, few patients initiate medication and retention remains a critical challenge across settings. Much remains to be learned about individual and structural factors that influence successful retention, especially among populations dispensed MOUD in outpatient settings. METHODS We examined individual and structural characteristics associated with MOUD treatment retention among a national sample of adults seeking MOUD treatment in outpatient substance use treatment settings using the 2017 Treatment Episode Dataset-Discharges (TEDS-D). The study assessed predictors of retention in MOUD using multivariate logistic regression and accelerated time failure models. RESULTS Of 130,300 episodes of MOUD treatment in outpatient settings, 36% involved a duration of care greater than six months. The strongest risk factors for treatment discontinuation by six months included being of younger age, ages 18-29 ((OR):0.52 [95%CI:0.50-0.54]) or 30-39 (OR:0.57 [95%CI:0.55-0.59); experiencing homelessness (OR: 0.70 [95%CI:0.66-0.73]); co-using methamphetamine (OR:0.48 [95%CI:0.45-0.51]); and being referred to treatment by a criminal justice source (OR:0.55 [95%CI:0.52-0.59) or by a school, employer, or community source (OR:0.71 [95%CI:0.66-0.76). CONCLUSIONS Improving retention in treatment is a pivotal stage in the OUD cascade of care and is critical to reducing overdose deaths. Efforts should prioritize interventions to improve retention among patients who are both prescribed and dispended MOUD, especially youth, people experiencing homelessness, polysubstance users, and people referred to care by the justice system who have especially short stays in care.
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Affiliation(s)
- Noa Krawczyk
- Department of Population Health, NYU Grossman School of Medicine, United States of America.
| | - Arthur Robin Williams
- Columbia University Department of Psychiatry, New York State Psychiatric Institute, United States of America
| | - Brendan Saloner
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, United States of America
| | - Magdalena Cerdá
- Department of Population Health, NYU Grossman School of Medicine, United States of America
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23
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Bhatraju EP, Fuller C, Grekin P, Rockman S, Peavy KM. Mortality in an Opioid Treatment Program. J Psychoactive Drugs 2021; 54:93-98. [PMID: 33840354 DOI: 10.1080/02791072.2021.1909189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This retrospective study examined mortality in an Opioid Treatment Program (OTP) with policies designed to admit and retain patients with as few barriers as possible. Methadone provided in the context of an OTP is known to decrease mortality and morbidity. Historically, patients have been discharged or turned away because of continued substance use. We examined patient deaths over three years in an OTP serving approximately 2400 patients daily. Demographics and causes of death were gathered from electronic health records and medical examiner reports. Pairwise comparisons were used to compare drug poisoning versus non-drug poisoning deaths. There were 155 deaths during the study period. The average age was 54, and half of the participants had positive results on their most recent drug screen. Forty one (26%) died from "drug poisoning." Drug poisoning deaths were more common among patients who: 1) had recent positive drug test results; 2) had documented alprazolam use; 3) were younger; 4) had shorter treatment durations; 5) were female. The majority of deaths were among long-term patients over 50 and were not caused by drug poisoning. These results support keeping patients in treatment despite ongoing drug use, and linking them to appropriate primary care.
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Affiliation(s)
- Elenore P Bhatraju
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA.,Evergreen Treatment Services, Seattle, WA, USA
| | - Caitlin Fuller
- Department of Clinical Psychology, Alliant International University, San Diego, CA, USA
| | - Paul Grekin
- Evergreen Treatment Services, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
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24
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Factors associated with early and later dropout from methadone maintenance treatment in specialist addiction clinics: a six-year cohort study using proportional hazards frailty models for recurrent treatment episodes. Drug Alcohol Depend 2021; 219:108466. [PMID: 33421801 DOI: 10.1016/j.drugalcdep.2020.108466] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Retention in methadone maintenance treatment (MMT) is associated with reduced illicit drug use, criminal activity, and mortality; however, many clients move in and out of MMT. This study aims to identify determinants of time to dropout of MMT across multiple treatment episodes in specialist addiction services in Ireland. METHODS Cohort study of persons attending specialist addiction clinics between 2010 and 2015. MMT episodes were periods of continuous treatment if there were no interruptions to treatment lasting > 7days. Proportional hazards frailty models were used to assess factors associated with time to dropout from recurrent MMT episodes at 3 (90 days) and 12 months (91-365 days). MMT episodes were right- censored at time of death, transfer to prison or primary care, and study end. RESULTS A total of 2,035 individuals experienced 4,969 MMT episodes, with 2,724 dropout events during the six-year follow-up. Factors associated with dropout at 3 months included low dose methadone (<60 mg/day) (HR = 1.49, 95% CI 1.29-1.73) and previous dropout (HR = 1.65, 95% CI 1.41-1.92). Adherence was protective (HR = 0.91, 95% CI 0.90-0.92). Dropout at 12 months was associated with low dose methadone (HR = 1.44, 95% CI 1.23-1.68), previous dropout (HR = 1.37, 95% CI 1.16-1.61), males (HR 1.26, 95% CI 1.06-1.50), benzodiazepines (HR = 1.22, 95% CI 1.03-1.45) and number of comorbidities (HR = 1.12, 95% CI 1.05-1.20); adherence was protective (HR = 0.86, 95% CI 0.84-0.87). CONCLUSIONS Clients with a previous history of treatment dropout and those on low dose methadone should be identified as high risk for both early and later dropout. Inversely, adherence to treatment, not missing methadone doses, is protective.
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25
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Bryson WC, Morasco BJ, Cotton BP, Thielke SM. Cannabis Use and Nonfatal Opioid Overdose among Patients Enrolled in Methadone Maintenance Treatment. Subst Use Misuse 2021; 56:697-703. [PMID: 33749499 DOI: 10.1080/10826084.2021.1892137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Some ecological studies found lower rates of opioid overdose in states with liberalized cannabis legislation, but results are mixed, and the association has not been analyzed in individuals. We quantified the association between cannabis use and nonfatal opioid overdose among individuals enrolled in methadone maintenance treatment (MMT) for opioid use disorder (OUD). METHODS We recruited a convenience sample of individuals enrolled in four MMT clinics in Washington State and southern New England who completed a one-time survey.Descriptive statistics and multivariate logistic regression compared the prevalence and risk of nonfatal opioid overdose in the past 12 months between participants reporting frequent (at least weekly) or infrequent (once or none) cannabis use in the past month. RESULTS Of 446 participants, 35% (n = 156) reported frequent cannabis use and 7% (n = 32) reported nonfatal opioid overdose in the past year. The prevalence of nonfatal opioid overdose was 3% among reporters of frequent cannabis use, and 9% among reporters of infrequent/no use (p = 0.02). After imputing missing data and controlling for demographic and clinical factors, the likelihood of self-reported nonfatal opioid overdose in the past year was 71% lower among reporters of frequent cannabis use in the past month (adjusted RR = 0.29, 95% CI 0.10-0.80, p = 0.02). CONCLUSIONS Among individuals enrolled in MMT, frequent cannabis use in the past month was associated with fewer self-reported nonfatal opioid overdoses in the past year. Methodological limitations caution against causal interpretation of this relationship. Additional studies are needed to understand the prospective impact of co-occurring cannabis on opioid-related outcomes.
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Affiliation(s)
- William C Bryson
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Benjamin J Morasco
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA.,Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
| | - Brandi P Cotton
- College of Nursing, University of Rhode Island, Providence, RI, USA
| | - Stephen M Thielke
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
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26
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Durand L, O'Driscoll D, Boland F, Keenan E, Ryan BK, Barry J, Bennett K, Fahey T, Cousins G. Do interruptions to the continuity of methadone maintenance treatment in specialist addiction settings increase the risk of drug-related poisoning deaths? A retrospective cohort study. Addiction 2020; 115:1867-1877. [PMID: 32034837 PMCID: PMC7540578 DOI: 10.1111/add.15004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/02/2019] [Accepted: 02/05/2020] [Indexed: 12/01/2022]
Abstract
AIMS To examine the risk of mortality associated with interruptions to the continuity of methadone maintenance treatment (MMT), including transfers between services, in opioid-dependent individuals attending specialist addiction services. DESIGN Retrospective cohort study using addiction services and primary care dispensing records, the National Methadone Register and National Drug-Related Death Index (NDRDI). SETTING Geographically defined population in Dublin, Ireland. PARTICIPANTS A total of 2899 people prescribed and dispensed methadone in specialist addiction services between January 2010 and December 2015. There were five exposure groups: weeks 1-4 following transfer between treatment providers; weeks 1-4 out of treatment; weeks 5-52 out of treatment; weeks 1-4 of treatment initiation; and weeks 5+ of continuous treatment (reference category). MEASUREMENTS Primary outcome: drug-related poisoning (DRP) deaths. Secondary outcome: all-cause mortality (ACM). Mortality rates calculated by dividing number of deaths (DRP; ACM) in exposure groups by person-years exposure. Unadjusted and adjusted Poisson regression (covariates age, sex, incarceration, methadone dose and comorbidities) estimated differences in mortality rates. FINDINGS There were 154 ACM deaths, 55 (35.7%) identified as DRP deaths. No deaths were observed in the first month following transfer between treatment providers. The risk of DRP mortality was highest in weeks 1-4 out of treatment [adjusted relative risk (aRR = 4.04, 95% confidence interval (CI) = 1.43-11.43, P = 0.009] and weeks 1-4 of treatment initiation (ARR = 3.4, 95% CI = 1.2-9.64, P = 0.02). Similarly, risk of ACM was highest in weeks 1-4 out of treatment (ARR = 11.78, 95% CI = 7.73-17.94, P < 0.001), weeks 1-4 of treatment initiation (aRR = 5.11, 95% CI = 2.95-8.83, P < 0.001) and weeks 5-52 off treatment (aRR = 2.04, 95% CI = 1.2-3.47, P = 0.009). CONCLUSIONS Interruptions to the continuity of methadone maintenance treatment by treatment provider do not appear to be periods of risk for drug-related poisoning or all-cause mortality deaths. Risk of drug related poisoning and all-cause mortality deaths appears to be greatest during the first 4 weeks of treatment initiation/re-initiation and after treatment cessation.
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Affiliation(s)
- Louise Durand
- School of Pharmacy and Biomolecular SciencesRoyal College of Surgeons in IrelandDublinIreland
| | | | - Fiona Boland
- HRB Centre for Primary Care ResearchRoyal College of Surgeons in IrelandDublinIreland
| | - Eamon Keenan
- HSE National Social Inclusion Office, Stewarts HospitalDublinIreland
| | - Benedict K. Ryan
- School of Pharmacy and Biomolecular SciencesRoyal College of Surgeons in IrelandDublinIreland
| | - Joseph Barry
- Department of Public Health and Primary CareTrinity College DublinIreland
| | - Kathleen Bennett
- Division of Population Health SciencesRoyal College of Surgeons in IrelandDublinIreland
| | - Tom Fahey
- Department of General Practice and HRB Centre for Primary Care ResearchRoyal College of Surgeons in IrelandDublinIreland
| | - Gráinne Cousins
- School of Pharmacy and Biomolecular SciencesRoyal College of Surgeons in IrelandDublinIreland
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27
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Frank D. "That's No Longer Tolerated": Policing Patients' Use of Non-opioid Substances in Methadone Maintenance Treatment. J Psychoactive Drugs 2020; 53:10-17. [PMID: 32996399 DOI: 10.1080/02791072.2020.1824046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The current overdose crisis in the United States emphasizes the importance of providing substance use treatment programs that are not only effective but tailored to meet the specific needs of the populations they serve. While Methadone Maintenance Treatment (MMT) is considered to be among the best strategies for reducing rates of opioid-involved overdose, its ability to attract and maintain patients may be hindered by a recent focus on policing the non-opioid substance use of people on the program. This paper uses interview data from treatment providers to examine how clinicians conceptualize and organize MMT in regards to patients' use of non-opioid drugs. Responses demonstrate that some treatment providers are increasingly monitoring their patients' use of non-opioid substances and punishing them for infractions, up to and including discharge from treatment. This approach will likely result in increasing rates of patient dropout and a lack of new admissions among people who use non-opioid substances. This article argues that including non-opioid substances in MMT's mandate restricts its ability to improve public health, including by preventing overdoses, and recommends instead that MMT adopt a more individualized approach, shaped by the needs and goals of the patient rather than those of the clinician.
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Affiliation(s)
- David Frank
- Rory Meyers College of Nursing, New York University, New York, NY, USA
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28
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Krawczyk N, Mojtabai R, Stuart E, Fingerhood M, Agus D, Lyons BC, Weiner JP, Saloner B. Opioid agonist treatment and fatal overdose risk in a state-wide US population receiving opioid use disorder services. Addiction 2020; 115:1683-1694. [PMID: 32096302 PMCID: PMC7426244 DOI: 10.1111/add.14991] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 12/17/2019] [Accepted: 01/27/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIMS Evidence from randomized controlled trials establishes that medication treatment with methadone and buprenorphine reduces opioid use and improves treatment retention. However, little is known about the role of such medications compared with non-medication treatments in mitigating overdose risk among US patient populations receiving treatment in usual care settings. This study compared overdose mortality among those in medication versus non-medication treatments in specialty care settings. DESIGN Retrospective cohort study using state-wide treatment data linked to death records. Survival analysis was used to analyze data in a time-to-event framework. SETTING Services delivered by 757 providers in publicly funded out-patient specialty treatment programs in Maryland, USA between 1 January 2015 and 31 December 2016. PARTICIPANTS A total of 48 274 adults admitted to out-patient specialty treatment programs in 2015-16 for primary diagnosis of opioid use disorder. MEASUREMENTS Main exposure was time in medication treatment (methadone/buprenorphine), time following medication treatment, time exposed to non-medication treatments and time following non-medication treatment. Main outcome was opioid overdose death during and after treatment. Hazard ratios were calculated using Cox proportional hazard regression. Propensity score weights were adjusted for patient information on sex, age, race, region of residence, marital and veteran status, employment, homelessness, primary opioid, mental health treatment, arrests and criminal justice referral. FINDINGS The study population experienced 371 opioid overdose deaths. Periods in medication treatment were associated with substantially reduced hazard of opioid overdose death compared with periods in non-medication treatment [adjusted hazard ratio (aHR) = 0.18, 95% confidence interval (CI) = 0.08-0.40]. Periods after discharge from non-medication treatment (aHR = 5.45, 95% CI = 2.80-9.53) and medication treatment (aHR = 5.85, 95% CI = 3.10-11.02) had similar and substantially elevated risks compared with periods in non-medication treatments. CONCLUSIONS Among Maryland patients in specialty opioid treatment, periods in treatment are protective against overdose compared with periods out of care. Methadone and buprenorphine are associated with significantly lower overdose death compared with non-medication treatments during care but not after treatment is discontinued.
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Affiliation(s)
- Noa Krawczyk
- Department of Population Health, NYU School of Medicine, New York, NY,Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Ramin Mojtabai
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Elizabeth Stuart
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Michael Fingerhood
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD,Johns Hopkins School of Medicine, Baltimore, MD
| | - Deborah Agus
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - B. Casey Lyons
- Office of Provider Engagement and Regulation, Maryland Department of Health, Catonsville, MD,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jonathan P. Weiner
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Brendan Saloner
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Baseline Factors Associated with Mortality in Patients Who Engaged in Buprenorphine Treatment for Opioid Use Disorder: a Cohort Study. J Gen Intern Med 2020; 35:2375-2382. [PMID: 32206993 PMCID: PMC7403281 DOI: 10.1007/s11606-020-05779-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 03/06/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Opioid agonist therapy (OAT) has been shown to reduce mortality in patients with opioid use disorder (OUD), yet mortality in individuals receiving OAT remains higher than in an age- and gender-matched population. OBJECTIVE To identify baseline risk factors in patients who engaged in buprenorphine treatment that are associated with this elevated risk of death. DESIGN We performed a retrospective cohort study from January 1, 2007, to December 31, 2018, using a centralized clinical data registry within a multi-hospital health system in Boston, MA, USA. PARTICIPANTS All adult patients who had ≥ 2 consecutive encounters with sublingual buprenorphine on the active medication list from January 1, 2007, to December 31, 2018. MAIN MEASURES We abstracted several sociodemographic, clinical, and healthcare use characteristics from the clinical data registry. The primary outcome was all-cause mortality and the secondary outcome was opioid overdose-related mortality. We performed multivariable cox regression to identify baseline characteristics independently associated with these outcomes. KEY RESULTS Of 5948 patients in the cohort, the majority were white (80.7%) and male (59.7%), with a mean age of 38.2 years. The all-cause mortality rate was 24.0 deaths per 1000 person-years. Baseline characteristics independently associated with an increased hazard of all-cause mortality included homelessness (adjusted hazard ratio [aHR] = 1.39; 95% confidence interval [CI] = 1.09, 1.78), an opioid on the active medication list (aHR = 1.28; 95% CI = 1.08, 1.52), and entry into the cohort during an inpatient hospitalization (aHR = 1.43; 95% CI = 1.18, 1.73). Homelessness was also associated with an increased hazard of opioid overdose-related mortality (aHR = 1.77; 95% CI = 1.25, 2.50). CONCLUSIONS We identified several novel and potentially modifiable predictors of mortality among patients engaging in buprenorphine treatment who remain at an increased risk of death compared with the general population. Understanding these risk factors can assist healthcare providers in risk stratification and inform the design of targeted interventions to improve outcomes in a high-risk patient population.
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30
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O’Connor AM, Cousins G, Durand L, Barry J, Boland F. Retention of patients in opioid substitution treatment: A systematic review. PLoS One 2020; 15:e0232086. [PMID: 32407321 PMCID: PMC7224511 DOI: 10.1371/journal.pone.0232086] [Citation(s) in RCA: 127] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 04/07/2020] [Indexed: 12/18/2022] Open
Abstract
Background Retention in opioid substitution (OST) treatment is associated with substantial reductions in all cause and overdose mortality. This systematic review aims to identify both protective factors supporting retention in OST, and risk factors for treatment dropout. Methods A systematic search was performed using MEDLINE, Embase, PsycInfo, CINAHL and Web of Science (January 2001 to October 2019). Randomised controlled trials (RCTs) and observational cohort studies reporting on retention rates and factors associated with retention in OST were included. Factors associated with treatment retention and dropout were explored according to the Maudsley Addiction Profile. A narrative synthesis is provided. Results 67 studies were included in this review (4 RCTs and 63 observational cohort studies; N = 294,592), all assessing factors associated with retention in OST or treatment dropout. The median retention rate across observational studies was approximately 57% at 12 months, which fell to 38.4% at three years. Studies included were heterogeneous in nature with respect to treatment setting, type of OST, risk factor assessment, ascertainment of outcome and duration of follow-up. While the presence of such methodological heterogeneity makes it difficult to synthesise results, there is limited evidence to support the influence of a number of factors on retention, including age, substance use, OST drug dose, legal issues, and attitudes to OST. Conclusions Younger age, substance use particularly cocaine and heroin use, lower doses of methadone, criminal activity/incarceration, and negative attitudes to MMT appear to be associated with reduced retention in OST. A consensus definition of retention is required to allow for comparability across future studies.
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Affiliation(s)
- Aisling Máire O’Connor
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Gráinne Cousins
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- * E-mail:
| | - Louise Durand
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Joe Barry
- Population Health Medicine, Public Health and Primary Care, Trinity College Dublin, Dublin, Ireland
| | - Fiona Boland
- Data Science Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
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Ataiants J, Roth AM, Mazzella S, Lankenau SE. Circumstances of overdose among street-involved, opioid-injecting women: Drug, set, and setting. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 78:102691. [PMID: 32086154 PMCID: PMC7302961 DOI: 10.1016/j.drugpo.2020.102691] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 01/23/2020] [Accepted: 01/27/2020] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Current discourses about the causes of the overdose crisis largely focus on the harmful effects of drugs. Prior research, however, indicates that drug use experience is shaped by complex interactions of drugs with physiological and mental "sets" of people who use drugs and the wider social and physical "setting." Zinberg's "drug, set, and setting" theoretical framework was applied to identify patterns in circumstances leading up to women's overdose. METHODS In-depth semi-structured interviews were conducted with 29 opioid-injecting street-involved women, clients of a Philadelphia harm reduction program. Qualitative analysis with deductive and inductive coding was utilized to examine transcripts for theory-driven and emerging themes. RESULTS Ten out of 29 women attributed their overdose to "drugs," reporting the unpredictable quality of street opioids, concurrent use of benzodiazepines, or chasing the "high." Thirteen women reported "set" as a type of circumstance where their emotional states were affected by a "good" or "bad" day, leading them to unusual drug consumption practices. Six women described "setting" type of circumstances where their overdose was preceded by a recent change in context, such as release from prison, which prompted unsafe drug use to address physiological or psychological dependence on drugs. CONCLUSION While all overdoses result from the pharmacological action of drugs, some overdoses were triggered by circumstances occurring in women's set or setting. Overdose prevention policies should embrace not only individual-level behavioral interventions, but also structural measures to address stress, social isolation, and risky drug use contexts that plague the lives of street-involved women who inject opioids.
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Affiliation(s)
- Janna Ataiants
- Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, 3215 Market St, Philadelphia, PA 19104, USA.
| | - Alexis M Roth
- Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, 3215 Market St, Philadelphia, PA 19104, USA
| | - Silvana Mazzella
- Prevention Point Philadelphia, 2913 Kensington Ave, Philadelphia, PA 19134, USA
| | - Stephen E Lankenau
- Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, 3215 Market St, Philadelphia, PA 19104, USA
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Why evidence still matters to general practice: James Mackenzie Lecture 2019. Br J Gen Pract 2020; 70:198-199. [DOI: 10.3399/bjgp20x709241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Pearce LA, Min JE, Piske M, Zhou H, Homayra F, Slaunwhite A, Irvine M, McGowan G, Nosyk B. Opioid agonist treatment and risk of mortality during opioid overdose public health emergency: population based retrospective cohort study. BMJ 2020; 368:m772. [PMID: 32234712 PMCID: PMC7190018 DOI: 10.1136/bmj.m772] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare the risk of mortality among people with opioid use disorder on and off opioid agonist treatment (OAT) in a setting with a high prevalence of illicitly manufactured fentanyl and other potent synthetic opioids in the illicit drug supply. DESIGN Population based retrospective cohort study. SETTING Individual level linkage of five health administrative datasets capturing drug dispensations, hospital admissions, physician billing records, ambulatory care reports, and deaths in British Columbia, Canada. PARTICIPANTS 55 347 people with opioid use disorder who received OAT between 1 January 1996 and 30 September 2018. MAIN OUTCOME MEASURES All cause and cause specific crude mortality rates (per 1000 person years) to determine absolute risk of mortality and all cause age and sex standardised mortality ratios to determine relative risk of mortality compared with the general population. Mortality risk was calculated according to treatment status (on OAT, off OAT), time since starting and stopping treatment (1, 2, 3-4, 5-12, >12 weeks), and medication type (methadone, buprenorphine/naloxone). Adjusted risk ratios compared the relative risk of mortality on and off OAT over time as fentanyl became more prevalent in the illicit drug supply. RESULTS 7030 (12.7%) of 55 347 OAT recipients died during follow-up. The all cause standardised mortality ratio was substantially lower on OAT (4.6, 95% confidence interval 4.4 to 4.8) than off OAT (9.7, 9.5 to 10.0). In a period of increasing prevalence of fentanyl, the relative risk of mortality off OAT was 2.1 (95% confidence interval 1.8 to 2.4) times higher than on OAT before the introduction of fentanyl, increasing to 3.4 (2.8 to 4.3) at the end of the study period (65% increase in relative risk). CONCLUSIONS Retention on OAT is associated with substantial reductions in the risk of mortality for people with opioid use disorder. The protective effect of OAT on mortality increased as fentanyl and other synthetic opioids became common in the illicit drug supply, whereas the risk of mortality remained high off OAT. As fentanyl becomes more widespread globally, these findings highlight the importance of interventions that improve retention on opioid agonist treatment and prevent recipients from stopping treatment.
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Affiliation(s)
- Lindsay A Pearce
- Health Economic Research Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, V6Z 1Y6, Canada
| | - Jeong Eun Min
- Health Economic Research Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, V6Z 1Y6, Canada
| | - Micah Piske
- Health Economic Research Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, V6Z 1Y6, Canada
| | - Haoxuan Zhou
- Health Economic Research Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, V6Z 1Y6, Canada
| | - Fahmida Homayra
- Health Economic Research Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, V6Z 1Y6, Canada
| | - Amanda Slaunwhite
- British Columbia Centre for Disease Control and Prevention, Vancouver, BC, V5Z 4R4, Canada
| | - Mike Irvine
- British Columbia Centre for Disease Control and Prevention, Vancouver, BC, V5Z 4R4, Canada
| | - Gina McGowan
- British Columbia Ministry of Mental Health and Addictions, Victoria, BC, V8W 9P1, Canada
| | - Bohdan Nosyk
- Health Economic Research Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, V6Z 1Y6, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, V5A 1S6, Canada
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34
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Mortality Among People With Opioid Use Disorder: A Systematic Review and Meta-analysis. J Addict Med 2020; 14:e118-e132. [DOI: 10.1097/adm.0000000000000606] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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35
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Lamont R, Rosic T, Sanger N, Samaan Z. Psychosis and Comorbid Opioid Use Disorder: Characteristics and Outcomes in Opioid Substitution Therapy. SCHIZOPHRENIA BULLETIN OPEN 2020; 1:sgaa007. [PMID: 32803158 PMCID: PMC7418864 DOI: 10.1093/schizbullopen/sgaa007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Substance use disorders are highly prevalent among individuals with psychotic disorders and are associated with negative outcomes. This study aims to explore differences in characteristics and treatment outcomes for individuals with psychotic disorders when compared with individuals with other nonpsychotic psychiatric disorders enrolled in treatment for opioid use disorder (OUD). METHODS Data were collected from a prospective cohort study of 415 individuals enrolled in outpatient methadone maintenance treatment (MMT). Psychiatric comorbidity was assessed using the Mini-International Neuropsychiatric Interview. Participants were followed for 12 months. Participant characteristics associated with having a psychotic disorder versus another nonpsychotic psychiatric disorder were explored by logistic regression analysis. RESULTS Altogether, 37 individuals (9%) with a psychotic disorder were identified. Having a psychotic disorder was associated with less opioid-positive urine drug screens (odds ratio [OR] = 0.97, 95% confidence interval [CI] = 0.95, 0.99, P = .046). Twelve-month retention in treatment was not associated with psychotic disorder group status (OR = 0.73, 95% CI = 0.3, 1.77, P = .485). Participants with psychotic disorders were more likely to be prescribed antidepressants (OR = 2.12, 95% CI = 1.06, 4.22, P = .033), antipsychotics (OR = 3.57, 95% CI = 1.74, 7.32, P = .001), mood stabilizers (OR = 6.61, 95% CI = 1.51, 28.97, P = .012), and benzodiazepines (OR = 2.22, 95% CI = 1.11, 4.43, P = .024). DISCUSSION AND CONCLUSIONS This study contributes to the sparse literature on outcomes of individuals with psychotic disorders and OUD-receiving MMT. Rates of retention in treatment and opioid use are encouraging and contrast to the widely held belief that these individuals do more poorly in treatment. Higher rates of coprescription of sedating and QTc-prolonging medications in this group may pose unique safety concerns.
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Affiliation(s)
- Rachel Lamont
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Tea Rosic
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Nitika Sanger
- Medical Sciences Graduate Program, McMaster University, Hamilton, ON, Canada
| | - Zainab Samaan
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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Bahji A, Cheng B, Gray S, Stuart H. Reduction in mortality risk with opioid agonist therapy: a systematic review and meta-analysis. Acta Psychiatr Scand 2019; 140:313-339. [PMID: 31419306 DOI: 10.1111/acps.13088] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Opioid agonist therapies are effective medications that can greatly improve the quality of life of individuals with opioid use disorder. However, there is significant uncertainty about the risks of cause-specific mortality in and out of treatment. OBJECTIVE This systematic review and meta-analysis explored the association between methadone and buprenorphine with cause-specific mortality among opioid-dependent persons. METHODS We searched six online databases to identify relevant cohort studies, calculating all-cause and overdose-specific mortality rates during periods in and out of treatment. We pooled mortality estimates using multivariate random effects meta-analysis of the crude mortality rate per 1000 person-years of follow-up as well as relative risks comparing mortality in vs. out of treatment. RESULTS A total of 32 cohort studies (representing 150 235 participants, 805 423.6 person-years, and 9112 deaths) met eligibility criteria. Crude mortality rates were substantially higher among methadone cohorts than buprenorphine cohorts. Relative risk reduction was substantially higher with methadone relative to buprenorphine when time in-treatment was compared to time out-of-treatment. Furthermore, the greatest mortality reduction was conferred during the first 4 weeks of treatment. Mortality estimates were substantially heterogeneous and varied significantly by country, region, and by the nature of the treatment provider. CONCLUSION Precautions are necessary for the safer implementation of opioid agonist therapy, including baseline assessments of opioid tolerance, ongoing monitoring during the induction period, education of patients about the risk of overdose, and coordination within healthcare services.
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Affiliation(s)
- A Bahji
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.,Department of Psychiatry, Queen's University, Kingston, ON, Canada.,Substance Treatment and Recovery Team, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - B Cheng
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - S Gray
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - H Stuart
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
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37
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Bukten A, Stavseth MR, Clasuen T. From restrictive to more liberal: variations in moratlity among patients in opioid maintenance treament over a 12-year period. BMC Health Serv Res 2019; 19:553. [PMID: 31391048 PMCID: PMC6686445 DOI: 10.1186/s12913-019-4382-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 07/30/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND As the effect of opioid maintenance treatment (OMT) on overdose mortality varies both between and within countries, treatment programs need to be evaluated in different treatment settings and over time within settings. We evaluated variations in mortality in a national programme: from the initial rollout as restrictive and low-capacity to its gradual change into more liberal and higher-volume. METHODS A 12-year prospective longitudinal cohort study including all persons (n = 6871) applying for and entering OMT in Norway (1997-2009). We followed all patients until 2009 or until death. We used crude mortality rates (CMR) to calculate overdose and all-cause mortality among patients in OMT before, during and after treatment, during a 12-year time-period. We also calculated variations in overdose and all-cause mortality over the course of treatment and after treatment termination. We fitted proportional hazards models with covariates to the data. RESULTS OMT significantly reduces risk of mortality compared to being outside of treatment. The reduction in overdose death was most substantial during the initial phase of the Norwegian OMT-programme, still; we consistently find that overdose deaths were more than halved in all calendar-periods throughout observation. We did not find an elevated risk of overdose death in the first weeks of treatment, nor in the first weeks after treatment cessation. CONCLUSION In Norway, OMT reduces overall mortality. Reduction in mortality is likely dependent of both treatment delivery and characteristics of the at-risk population.
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Affiliation(s)
- Anne Bukten
- Norwegian Centre for Addiction Research, University of Oslo, Kirkveien 166, N-0407 Oslo, Norway
| | | | - Thomas Clasuen
- Norwegian Centre for Addiction Research, University of Oslo, Kirkveien 166, N-0407 Oslo, Norway
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38
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Ghaderi A, Rasouli‐Azad M, Vahed N, Banafshe HR, Soleimani A, Omidi A, Ghoreishi FS, Asemi Z. Clinical and metabolic responses to crocin in patients under methadone maintenance treatment: A randomized clinical trial. Phytother Res 2019; 33:2714-2725. [DOI: 10.1002/ptr.6445] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/14/2019] [Accepted: 06/26/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Amir Ghaderi
- Department of Addiction Studies, School of MedicineKashan University of Medical Sciences Kashan Iran
- Clinical Research Development Unit – Matini/Kargarnejad HospitalKashan University of Medical Sciences Kashan Iran
| | - Morad Rasouli‐Azad
- Education and Psychology Department, College of EducationUniversity of Raparin Kurdistan Region Iraq
| | - Neda Vahed
- Addiction Department, School of Behavioral Sciences and Mental Health (Tehran Institute of Psychiatry)Iran University of Medical Sciences Tehran Iran
| | - Hamid Reza Banafshe
- Department of Addiction Studies, School of MedicineKashan University of Medical Sciences Kashan Iran
- Physiology Research CenterKashan University of Medical Sciences Kashan Iran
| | - Anvar Soleimani
- Department of Clinical Biochemistry, Faculty of MedicineMashhad University of Medical Sciences Mashhad Iran
| | - Abdollah Omidi
- Department of Clinical Psychology, School of MedicineKashan University of Medical Science Kashan Iran
| | - Fatemeh Sadat Ghoreishi
- Clinical Research Development Unit – Matini/Kargarnejad HospitalKashan University of Medical Sciences Kashan Iran
- Department of Psychiatry, School of MedicineKashan University of Medical Science Kashan Iran
| | - Zatollah Asemi
- Research Center for Biochemistry and Nutrition in Metabolic DiseasesKashan University of Medical Sciences Kashan Iran
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Truong C, Krawczyk N, Dejman M, Marshall-Shah S, Tormohlen K, Agus D, Bass J. Challenges on the road to recovery: Exploring attitudes and experiences of clients in a community-based buprenorphine program in Baltimore City. Addict Behav 2019; 93:14-19. [PMID: 30682677 PMCID: PMC6528177 DOI: 10.1016/j.addbeh.2019.01.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 10/23/2018] [Accepted: 01/14/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE This qualitative study identifies and describes experiences and challenges to retention of individuals with opioid use disorder (OUD) who participated in a low-threshold combined buprenorphine-peer support treatment program in Baltimore. METHODS In-depth semi-structured interviews with staff and former clients of the Project Connections Buprenorphine Program (PCBP) (9 people) and focus group discussions with current and previous clients of PCBP (7 people) were conducted. Content analysis was used to extract themes regarding barriers to enrolling and remaining in, and transitioning from the program. RESULTS Primary challenges identified by the participants included struggles with cravings and symptoms of withdrawal, comorbid mental health issues, criminal justice system involvement, medication stigma, and conflicts over level of flexibility regarding program requirements and the role of employment. CONCLUSIONS This study identified several obstacles clients face when seeking care through a combined buprenorphine-peer support model. Findings highlight potential programmatic factors that can be improved and additional resources that may support treatment retention rates and better outcomes. Despite challenges, low-threshold and community-based programs can increase access to effective maintenance treatment for OUD, especially among vulnerable populations who may not have access to formal health services.
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Affiliation(s)
- C Truong
- Mental Health Department, Johns Hopkins Bloomberg School of Public Health, Hampton House 624 N. Broadway, Floor 8, Baltimore, MD 21205, United States.
| | - N Krawczyk
- Mental Health Department, Johns Hopkins Bloomberg School of Public Health, Hampton House 624 N. Broadway, Floor 8, Baltimore, MD 21205, United States; Behavioral Health Leadership Institute, 2200 Arden Road, Baltimore, MD 21209, United States.
| | - M Dejman
- Mental Health Department, Johns Hopkins Bloomberg School of Public Health, Hampton House 624 N. Broadway, Floor 8, Baltimore, MD 21205, United States.
| | - S Marshall-Shah
- Mental Health Department, Johns Hopkins Bloomberg School of Public Health, Hampton House 624 N. Broadway, Floor 8, Baltimore, MD 21205, United States.
| | - K Tormohlen
- Mental Health Department, Johns Hopkins Bloomberg School of Public Health, Hampton House 624 N. Broadway, Floor 8, Baltimore, MD 21205, United States.
| | - D Agus
- Mental Health Department, Johns Hopkins Bloomberg School of Public Health, Hampton House 624 N. Broadway, Floor 8, Baltimore, MD 21205, United States; Behavioral Health Leadership Institute, 2200 Arden Road, Baltimore, MD 21209, United States.
| | - J Bass
- Mental Health Department, Johns Hopkins Bloomberg School of Public Health, Hampton House 624 N. Broadway, Floor 8, Baltimore, MD 21205, United States.
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Steer CD, Macleod J, Tilling K, Lim AG, Marsden J, Millar T, Strang J, Telfer M, Whitaker H, Vickerman P, Hickman M. The impact of opiate substitution treatment on mortality risk in drug addicts: a natural experiment study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Background
Opiate substitution treatment (OST) is the main treatment for people addicted to heroin and other opioid drugs. However, there is limited information on how the delivery of this treatment affects mortality risk.
Objectives
To investigate the associations of mortality risk with periods during treatment and following cessation of treatment, medication type, co-prescription of other medication and dosing regimens during titration and detoxification. The trends with time of prescribed medication, dose and treatment duration were also explored.
Design
Prospective longitudinal observational study.
Setting
UK primary care between 1998 and 2014.
Participants
A total of 12,780 patients receiving methadone, buprenorphine or dihydrocodeine.
Main outcome measures
All-cause mortality relating to 657 deaths and drug-related poisoning relating to 113 deaths.
Data sources
Clinical Practice Research Datalink with linked information on cause of death from the Office for National Statistics.
Results
For both outcomes, the lowest mortality risk was observed after 4 weeks of treatment and the highest risk was observed in the first 4 weeks following cessation of treatment [e.g. for drug-related poisoning, incidence rate ratio (IRR) 8.15, 95% confidence interval (CI) 5.45 to 12.19]. There was evidence that the treatment period risks varied with OST medication. The largest difference in risk was for the first 4 weeks of treatment for both outcomes, with patients on buprenorphine being at lower risk than those on methadone (e.g. for drug-related poisoning, IRR 0.08, 95% CI 0.01 to 0.48). The co-prescription of benzodiazepines was associated with linearly increasing the risk of drug-related deaths by dose (IRR 2.02, 95% CI 1.66 to 2.47), whereas z-drugs (zolpidem, zopiclone and zaleplon) were associated with increased risk of both all-cause (IRR 1.83, 95% CI 1.59 to 2.12) and drug-related (IRR 3.31, 95% CI 2.45 to 4.47) mortality. There was weak evidence that higher initial and final doses were associated with increased all-cause mortality risk. In the first 4 weeks of treatment, the risk increased by 4% for each 5-mg increment in methadone dose (1-mg increase in buprenorphine) (hazard ratio 1.04, 95% CI 1.00 to 1.09). In the first 4 weeks after treatment ceased, a similar increment in final dose increased the risk by 3% (hazard ratio 1.03, 95% CI 0.99 to 1.07). There were too few deaths to evaluate the effects on drug-related poisoning. The proportion of OST patients receiving buprenorphine increased between 1998 and 2006. Median treatment duration was consistently shorter for buprenorphine than for methadone for each year studied (overall median duration of 48 and 106 days, respectively).
Limitations
As this was an observational study, the possibility remains of bias from unmeasured factors, which covariate adjustment and inverse probability weighting can eliminate only partially.
Conclusions
Using buprenorphine as an alternative to methadone may not reduce mortality overall despite resulting in lower IRRs from shorter treatment duration. Clinical guidance needs to consider strengthening warnings about the co-prescription of a range of drugs for OST patients.
Future work
Our analyses need to be replicated using other clinical data sets in the UK and in other countries. New interventions and trials are required to investigate improving the retention of OST patients in primary care.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Colin D Steer
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - John Macleod
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kate Tilling
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Aaron G Lim
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - John Marsden
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Tim Millar
- Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester, UK
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | | | - Heather Whitaker
- Department of Mathematics and Statistics, The Open University, Milton Keynes, UK
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Enman NM, Reyes BAS, Shi Y, Valentino RJ, Van Bockstaele EJ. Sex differences in morphine-induced trafficking of mu-opioid and corticotropin-releasing factor receptors in locus coeruleus neurons. Brain Res 2018; 1706:75-85. [PMID: 30391476 DOI: 10.1016/j.brainres.2018.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 10/24/2018] [Accepted: 11/01/2018] [Indexed: 01/18/2023]
Abstract
The locus coeruleus (LC)-norepinephrine (NE) system is a key nucleus in which endogenous opioid and stress systems intersect to regulate the stress response. LC neurons of male rats become sensitized to stress following chronic morphine administration. Whether sex dictates this pattern of opioid-induced plasticity has not been demonstrated. Delineating the neurobiological adaptations produced by chronic opioids will enhance our understanding of stress vulnerability in opioid-dependent individuals, and may reveal how stress negatively impacts addiction recovery. In the present study, the effect of chronic morphine on the subcellular distribution of mu-opioid (MOR) and CRF receptors (CRFR) was investigated in the LC of male and female rats using immunoelectron microscopy. Results showed that placebo-treated females exhibited higher MOR and CRFR cytoplasmic distribution ratio when compared to placebo-treated males. Chronic morphine exposure induced a shift in the distribution of MOR immunogold-silver particles from the plasma membrane to the cytoplasm selectively in male LC neurons. Interestingly, chronic morphine exposure induced CRFR recruitment to the plasma membrane of both male and female LC neurons. These findings provide a potential mechanism by which chronic opioid administration increases stress vulnerability in males and females via an increase in surface availability of CRFR in LC neurons. However, our results also support the notion that cellular adaptations to chronic opioids differ across the sexes as redistribution of MOR following morphine exposure was only observed in male LC neurons.
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Affiliation(s)
- Nicole M Enman
- Department of Pharmacology and Physiology, College of Medicine, Drexel University, Philadelphia, PA 19102, USA.
| | - Beverly A S Reyes
- Department of Pharmacology and Physiology, College of Medicine, Drexel University, Philadelphia, PA 19102, USA.
| | - Yufan Shi
- Department of Pharmacology and Physiology, College of Medicine, Drexel University, Philadelphia, PA 19102, USA
| | - Rita J Valentino
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
| | - Elisabeth J Van Bockstaele
- Department of Pharmacology and Physiology, College of Medicine, Drexel University, Philadelphia, PA 19102, USA.
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Variation Overtime among Patients of the Six Methadone Maintenance Treatment Clinics in Thai Nguyen from 2011 to 2015. BIOMED RESEARCH INTERNATIONAL 2018; 2018:9081968. [PMID: 30175150 PMCID: PMC6106799 DOI: 10.1155/2018/9081968] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 07/04/2018] [Accepted: 07/22/2018] [Indexed: 11/25/2022]
Abstract
Background Methadone Maintenance Treatment (MMT) program's success depends on the likelihood of reducing drop-out rate and keeping patients remaining in the program. There have been neither comprehensive studies about variation among patients who have been experiencing MMT for long period nor prediction of MMT period in which the risk of drop-out would be the highest in Thai Nguyen, a northern mountainous province where the MMT was established in 2011. Objectives To analyze variation of the MMT population through indicators of drop-out and death, re-enrolment, and retention rate in the six Thai Nguyen MMT clinics. Methods A retrospective study by reviewing daily treatment notebooks of the six MMT clinics in Thai Nguyen to identify events of drop-out, death, reenrolment among 2,567 patients registered from 12 May 2011 to 6 September 2015. Results Cumulative hazard of drop-out over period from the first to the fourth year of MMT treatment has an increasing trend at 0.15; 0.31; 0.46; and 0.61, respectively. The cumulative probability of re-enrolment among 740 patients who have already quit the MMT program and then returned slightly increased from 0.07 to 0.16 between the first years and the fourth year in which the highest returning rate occurred within the first 2 years after drop-out. The cumulative retention rate decreased annually and stayed at 71.7% after 4 years of running the MMT. Conclusions MMT patients and their families should be informed and consulted about the highest risk period of drop-out and also about period when drop-out patients are most likely to reenter the MMT. Counseling adherence for patients should be conducted not only at the beginning but also during the ongoing MMT and play an extremely important role in reducing drop-out of the program while special counseling should also be reenforced for the re-enrolment patients of MMT.
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Hickman M, Steer C, Tilling K, Lim AG, Marsden J, Millar T, Strang J, Telfer M, Vickerman P, Macleod J. The impact of buprenorphine and methadone on mortality: a primary care cohort study in the United Kingdom. Addiction 2018; 113:1461-1476. [PMID: 29672985 PMCID: PMC6282737 DOI: 10.1111/add.14188] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 12/28/2017] [Accepted: 02/05/2018] [Indexed: 01/18/2023]
Abstract
AIMS To estimate whether opioid substitution treatment (OST) with buprenorphine or methadone is associated with a greater reduction in the risk of all-cause mortality (ACM) and opioid drug-related poisoning (DRP) mortality. DESIGN Cohort study with linkage between clinical records from Clinical Practice Research Datalink and mortality register. SETTING UK primary care. PARTICIPANTS A total of 11 033 opioid-dependent patients who received OST from 1998 to 2014, followed-up for 30 410 person-years. MEASUREMENTS Exposure to methadone (17 373, 61%) OST episodes or buprenorphine (9173, 39%) OST episodes. ACM was available for all patients; information on cause of death and DRP was available for 5935 patients (54%) followed-up for 16 363 person-years. Poisson regression modelled mortality by treatment period with an interaction between OST type and treatment period (first 4 weeks on OST, rest of time off OST, first 4 weeks off OST, rest of time out of OST censored at 12 months) to test whether ACM or DRP differed between methadone and buprenorphine. Inverse probability weights were included to adjust for confounding and balance characteristics of patients prescribed methadone or buprenorphine. FINDINGS ACM and DRP rates were 1.93 and 0.53 per 100 person-years, respectively. DRP was elevated during the first 4 weeks of OST [incidence rate ratio (IRR) = 1.93 95% confidence interval (CI) = 0.97-3.82], the first 4 weeks off OST (IRR = 8.15, 95% CI = 5.45-12.19) and the rest of time out of OST (IRR = 2.13, 95% CI = 1.47-3.09) compared with mortality risk from 4 weeks to end of treatment. Patients on buprenorphine compared with methadone had lower ACM rates in each treatment period. After adjustment, there was evidence of a lower DRP risk for patients on buprenorphine compared with methadone at treatment initiation (IRR = 0.08, 95% CI = 0.01-0.48) and rest of time on treatment (IRR = 0.37, 95% CI = 0.17-0.79). Treatment duration (mean and median) was shorter on buprenorphine than methadone (173 and 40 versus 363 and 111, respectively). Model estimates suggest that there was a low probability that methadone or buprenorphine reduced the number of DRP in the population: 28 and 21%, respectively. CONCLUSIONS In UK general medical practice, opioid substitution treatment with buprenorphine is associated with a lower risk of all-cause and drug-related poisoning mortality than methadone. In the population, buprenorphine is unlikely to give greater overall protection because of the relatively shorter duration of treatment.
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Affiliation(s)
- Matthew Hickman
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Colin Steer
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Kate Tilling
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Aaron G. Lim
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - John Marsden
- Addictions Department, Institute of Psychiatry, Psychiatry and NeuroscienceKing's College LondonLondonUK
| | - Tim Millar
- Centre for Mental Health and Safety, School of Health SciencesThe University of ManchesterManchesterUK
| | - John Strang
- Addictions Department, Institute of Psychiatry, Psychiatry and NeuroscienceKing's College LondonLondonUK
| | | | - Peter Vickerman
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - John Macleod
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
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Pierce M, Millar T, Robertson JR, Bird SM. Ageing opioid users' increased risk of methadone-specific death in the UK. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 55:121-127. [PMID: 29573622 PMCID: PMC6004035 DOI: 10.1016/j.drugpo.2018.02.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 01/15/2018] [Accepted: 02/12/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND The first evidence that the hazard ratio (HR) for methadone-specific death rises more steeply with age-group than for all drug-related deaths (DRDs) came from Scotland's cohort of 33,000 methadone-prescription clients. We aim to examine, for England, whether illicit opioid users' risk of methadone-specific death increases with age; and to pool age-related HRs for methadone-specific deaths with those for Scotland's methadone-prescription clients. METHODS The setting is all services in England that provide publicly-funded, structured treatment for illicit opioid users, the methodology linkage of the English National Drug Treatment Monitoring System and mortality database, and key measurements are DRDs, methadone-specific DRDs, or heroin-specific DRDs, by age-group and gender, with proportional hazards adjustment for substances used, injecting status and periods in/out of treatment. RESULTS Linkage was achieved for 129,979 adults receiving prescribing treatment modalities for opioid dependence during April 2005 to March 2009 and followed-up for 378,009 person-years (pys). There were 1,266 DRDs: 271 methadone-specific (7 per 10,000 pys: irrespective of gender) and 473 heroin-specific (15 per 10,000 pys for males, 7 for females). Methadone-specific DRD-rate per 10,000 person-years was 3.5 (95% CI: 2.7-4.4) at 18-34 years, 8.9 (CI: 7.3-10.5) at 35-44 years and 18 (CI: 13.8-21.2) at 45+ years; heroin-specific DRD-rate was unchanged with age. Relative to 25-34 years, pooled HRs for UK clients' methadone-specific deaths were: 0.87 at <25 years (95% CI: 0.56-1.35); 2.14 at 35-44 years (95% CI: 1.76-2.60); 3.75 at 45+ years (95% CI: 2.99-4.70). CONCLUSION International testing and explanation are needed of UK's sharp age-related increase in the risk of methadone-specific death. Clients should be alerted that their risk of methadone-specific death increases as they age.
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Affiliation(s)
- Matthias Pierce
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester M13 9PL, United Kingdom
| | - Tim Millar
- Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester M13 9PL, United Kingdom
| | - J Roy Robertson
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh EH16 4UX, United Kingdom
| | - Sheila M Bird
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh EH16 4UX, United Kingdom; MRC Biostatistics Unit, University of Cambridge, School of Clinical Medicine, Institute for Public Health, Cambridge CB2 0SR, United Kingdom; Department of Mathematics and Statistics, University of Strathclyde, Glasgow G1 1XH, United Kingdom.
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Walton G, Dong H, Milloy MJ, DeBeck K, Kerr T, Wood E, Hayashi K. Increasing availability of benzodiazepines among people who inject drugs in a Canadian setting. Subst Abus 2018; 39:69-76. [PMID: 28727956 DOI: 10.1080/08897077.2017.1356798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Benzodiazepine misuse is associated with mortality and is common among people who inject drugs (PWID). This study aimed to examine the temporal trends in the availability of benzodiazepines among PWID in a Canadian setting, and to identify factors associated with more immediate access to benzodiazepines. METHODS Data were derived from 3 prospective cohorts of PWID in Vancouver, Canada, between June 2012 and May 2015. The primary outcome was the perceived availability of benzodiazepines, measured in 3 levels: not available, delayed availability (available in ≥10 minutes), and immediate availability (available in <10 minutes). The authors used multivariable generalized estimating equations to identify factors associated with availability of benzodiazepines. RESULTS In total, 1641 individuals were included in these analyses. In multivariable analyses, factors associated with immediate benzodiazepine availability included incarceration (adjusted odds ratio [AOR]: 1.42, 95% confidence interval [CI]: 1.06, 1.89) and participation in methadone maintenance therapy (MMT) (AOR: 1.35, 95% CI: 1.14, 1.60). Factors associated with delayed benzodiazepine availability included incarceration (AOR: 1.45, 95% CI: 1.02, 2.07) and participation in MMT (AOR: 1.77, 95% CI: 1.48, 2.12). Benzodiazepine availability increased throughout the study period for both immediate (AOR: 1.14, 95% CI: 1.10, 1.18 per 6-month follow-up period) and delayed (AOR: 1.17, 95% CI: 1.12, 1.22 per 6-month follow-up period) availability. CONCLUSIONS Among our sample of PWID, benzodiazepine availability is increasing and was associated with health and criminal justice system characteristics. Our findings indicate a need to examine prescribing practices and educate both PWID and health care providers about the risks associated with benzodiazepine use.
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Affiliation(s)
- Geoffrey Walton
- a British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital , Vancouver , British Columbia , Canada.,b Department of Medicine , University of British Columbia , Vancouver , British Columbia , Canada
| | - Huiru Dong
- a British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital , Vancouver , British Columbia , Canada
| | - M J Milloy
- a British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital , Vancouver , British Columbia , Canada.,b Department of Medicine , University of British Columbia , Vancouver , British Columbia , Canada
| | - Kora DeBeck
- a British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital , Vancouver , British Columbia , Canada.,c School of Public Policy , Simon Fraser University , Vancouver , British Columbia , Canada
| | - Thomas Kerr
- a British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital , Vancouver , British Columbia , Canada
| | - Evan Wood
- a British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital , Vancouver , British Columbia , Canada.,b Department of Medicine , University of British Columbia , Vancouver , British Columbia , Canada
| | - Kanna Hayashi
- a British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital , Vancouver , British Columbia , Canada.,d Faculty of Health Sciences , Simon Fraser University , Burnaby , British Columbia , Canada
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Molist G, Brugal MT, Barrio G, Mesías B, Bosque-Prous M, Parés-Badell O, de la Fuente L. Effect of ageing and time since first heroin and cocaine use on mortality from external and natural causes in a Spanish cohort of drug users. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 53:8-16. [PMID: 29268239 DOI: 10.1016/j.drugpo.2017.11.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 11/10/2017] [Accepted: 11/20/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND We aimed to assess the effect of ageing and time since first heroin/cocaine use on cause-specific mortality risk and age disparities in excess mortality among heroin (HUs) and cocaine users (CUs) in Spain. METHODS A cohort of 15,305 HUs and 11,905 CUs aged 15-49 starting drug treatment during 1997-2007 in Madrid and Barcelona was followed until December 2008. Effects of ageing and time since first heroin/cocaine use were estimated using a competing risk Cox model and the relative and absolute excess mortality compared to the general population through directly age-sex standardized rate ratios (SRRs) and differences (SRDs), respectively. RESULTS Mortality risk from natural causes increased with time since first heroin use, whereas that from overdose declined after having peaked in the first quinquennium. Significant effects of time since first cocaine use were not identified, although fatal overdose risk seemed higher in CUs after five years. Mortality risk from natural causes (HUs and CUs), injuries (HUs), and overdoses (CUs) increased with age, the latter without reaching statistical significance. Crude mortality rates from overdoses and injuries remained very high at age 40-59 among both HUs (595 and 217 deaths/100,000 person-years, respectively) and CUs (191 and 88 deaths/100,000 person-years). SRDs from all and natural causes were much higher at age 40-59 than 15-29 in both HUs (2134 vs. 834 deaths/100,000 person-years) and CUs (927 vs. 221 deaths/100,000 person-years), while the opposite occurred with SRRs. CONCLUSION The high mortality risk among HUs and CUs at all ages from both external and natural causes, and increased SRDs with ageing, suggest that high-level healthcare and harm reduction services should be established early and maintained throughout the lifetime of these populations.
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Affiliation(s)
- Gemma Molist
- Área de Recerca i Innovació, Hospital General de Granollers, Barcelona, Spain, Spain; Consortium for Biomedical Research in Epidemiology & Public Health (CIBERESP), Madrid, Spain.
| | - M Teresa Brugal
- Public Health Agency of Barcelona, Barcelona, Spain; Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona, Spain.
| | - Gregorio Barrio
- National School of Public Health, Carlos III Health Institute, Madrid, Spain.
| | | | - Marina Bosque-Prous
- Public Health Agency of Barcelona, Barcelona, Spain; Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona, Spain.
| | - Oleguer Parés-Badell
- Public Health Agency of Barcelona, Barcelona, Spain; Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona, Spain.
| | - Luis de la Fuente
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBERESP), Madrid, Spain; National Epidemiology Center, Carlos III Health Institute, Madrid, Spain.
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Akhgari M, Amini-Shirazi N, Iravani FS. Forensic Toxicology Perspectives of Methadone-associated Deaths in Tehran, Iran, a 7-year Overview. Basic Clin Pharmacol Toxicol 2017; 122:436-441. [PMID: 29076627 DOI: 10.1111/bcpt.12930] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 10/20/2017] [Indexed: 02/02/2023]
Abstract
Methadone has a long history of pain relief and successful substitute for maintenance treatment in heroin and narcotic addiction. The aim of the study was to assess the trends of methadone-associated deaths in Tehran, Iran, in 2009-2015, from a forensic toxicology point of view. All methadone-associated deaths during this 7-year study period were evaluated according to demographic parameters and forensic toxicology analysis results. Results showed that 1274 cases of methadone-associated deaths were investigated during the study period. The incidence rate of methadone-associated deaths had risen 7.7 times in 2015 in comparison with 2009 (p < 0.05). The majority of cases were men (90.35%), aged from 20 to 40 years. About 80% of cases had shown positive results for other drugs and poisons in combination with methadone. Methamphetamine and tramadol were the most drugs detected in post-mortem samples. Death rates among methadone users in Tehran, Iran, increased year by year during 2009-2015. These findings raise the attention to the concomitant use of drugs with the need for changes in regulation and regulatory policy to restrict access and use of controlled drugs.
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Affiliation(s)
- Maryam Akhgari
- Legal Medicine Research Center, Legal Medicine Organization, Tehran, Iran
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48
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Akhgari M, Amini-Shirazi N, Iravani FS. Forensic Toxicology Perspectives of Methadone-associated Deaths in Tehran, Iran, a 7-year Overview. Basic Clin Pharmacol Toxicol 2017. [DOI: https://doi.org/10.1111/bcpt.12930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Maryam Akhgari
- Legal Medicine Research Center; Legal Medicine Organization; Tehran Iran
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49
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Lloyd B, Zahnow R, Barratt MJ, Best D, Lubman DI, Ferris J. Exploring mortality among drug treatment clients: The relationship between treatment type and mortality. J Subst Abuse Treat 2017; 82:22-28. [DOI: 10.1016/j.jsat.2017.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 08/30/2017] [Accepted: 09/01/2017] [Indexed: 01/18/2023]
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Hui D, Weinstein ZM, Cheng DM, Quinn E, Kim H, Labelle C, Samet JH. Very early disengagement and subsequent re-engagement in primary care Office Based Opioid Treatment (OBOT) with buprenorphine. J Subst Abuse Treat 2017; 79:12-19. [PMID: 28673522 PMCID: PMC5522736 DOI: 10.1016/j.jsat.2017.05.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 05/11/2017] [Accepted: 05/15/2017] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Patients with opioid use disorder often require multiple treatment attempts before achieving stable recovery. Rates of disengagement from buprenorphine are highest in the first month of treatment and termination of buprenorphine therapy results in return to use rates as high as 90%. To better characterize these at-risk patients, this study aims to describe: 1) the frequency and characteristics of patients with very early disengagement (≤1month) from Office Based Opioid Treatment (OBOT) with buprenorphine and 2) the frequency and characteristics of patients who re-engage in care at this same OBOT clinic within 2years, among the subset of very early disengagers. METHODS This is a retrospective cohort study of adult patients enrolled in a large urban OBOT program. Descriptive statistics were used to characterize the sample and the proportion of patients with very early (≤1month) disengagement and their re-engagement. Multivariable logistic regression models were used to identify patient characteristics associated with the outcomes of very early disengagement and re-engagement. Potential predictors included: sex, age, race/ethnicity, education, employment, opioid use history, prior substance use treatments, urine drug testing, and psychiatric diagnoses. RESULTS Overall, very early disengagement was unusual, with only 8.4% (104/1234) of patients disengaging within the first month. Among the subset of very early disengagers with 2years of follow-up, the proportion who re-engaged with this OBOT program in the subsequent 2years was 11.9% (10/84). Urine drug test positive for opiates within the first month (AOR: 2.01, 95% CI: 1.02-3.93) was associated with increased odds of very early disengagement. Transferring from another buprenorphine prescriber (AOR: 0.09, 95% CI: 0.01-0.70) was associated with decreased odds of very early disengagement. No characteristics were significantly associated with re-engagement. CONCLUSIONS Early disengagement is uncommon; however, continued opioid use appeared to be associated with higher odds of treatment disengagement and these patients may warrant additional support. Re-engagement was uncommon, suggesting the need for a more formal explicit system to encourage and facilitate re-engagement among patients who disengage.
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Affiliation(s)
- David Hui
- Boston University School of Medicine, 72 East Concord St., Boston, MA 02118, United States.
| | - Zoe M Weinstein
- Boston University School of Medicine/Boston Medical Center, Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, United States.
| | - Debbie M Cheng
- Boston University School of Public Health, Department of Biostatistics, 801 Massachusetts Avenue, 3rd Floor, Boston, MA 02118, United States.
| | - Emily Quinn
- Boston University School of Public Health, Data Coordinating Center, 85 East Newton St, M921, Boston, MA 02118, United States.
| | - Hyunjoong Kim
- Boston University School of Medicine, 72 East Concord St., Boston, MA 02118, United States.
| | - Colleen Labelle
- Boston University School of Medicine/Boston Medical Center, Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, United States.
| | - Jeffrey H Samet
- Boston University School of Medicine/Boston Medical Center, Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, United States; Boston University School of Public Health, Department of Community Health Sciences, 801 Massachusetts Avenue, 4th Floor, Boston, MA 02118, United States.
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