From methadone to buprenorphine: Changes during a 10year period within a national opioid maintenance treatment programme

Opioid overdose deaths and the expansion of opioid agonist treatment: a population-based prospective cohort study

BACKGROUND AND AIM

Effective policies to reduce drug-related overdoses remain a public health priority. We aimed to estimate the causal effects of a national opioid agonist treatment (OAT) program on population level drug fatalities.

DESIGN

Population-based prospective cohort study exploiting supply driven variation in treatment uptake across cohort-age groups generated by the introduction and scale-up of a national OAT program. A Poisson difference-in-differences model with an intention-to-treat design was used to assess how treatment uptake altered the age profile of risks and infer treatment effects on drug fatalities.

SETTING

Norway, from 1996 through 2016.

CASES

The data include a total of 5634 drug-related overdose deaths and cover the introduction of the Norwegian OAT program in 1998 and its initial growth period, reaching 12 286 ever-treated recipients by 2016.

MEASUREMENTS

Fatal opioid-related overdoses were defined as deaths with a primary cause assigned an International Classification of Diseases 10th Revision (ICD-10) code F11, or X42, X44, X62 or X64 in combination with T40.0-T40.4. Other non-opioid related fatal overdoses were defined by a primary cause registered as F12, F14, F15, F16 or F19, or X42, X44, X62 or 64 in combination with T40.5-T40.9.

FINDINGS

An additional 887 deaths (95% credibility interval [CI] = 265-1563) would have been expected in the absence of OAT, which implies one death avoided per 111 (95% CI = 61-342) treatment-exposed person-years. At scale, the program reduced annual overdose mortality by 27% in 2016 (95% CI = 10%-41%) relative to a no-OAT counterfactual, corresponding to 99 fewer expected fatal overdoses (95% CI = 28-180) in 2016. Analysing fatal opioid-related and other drug overdoses separately found similar numbers for avoided opioid-related fatalities (921, with 95% CI = 373-1526) and no treatment effects on non-opioid related fatalities (-38, with 95% CI = -193-154).

CONCLUSION

The introduction and rapid scale-up of a national opioid agonist treatment program in Norway was associated with substantial and plausibly causal reductions in drug fatalities.

Life satisfaction among individuals with opioid use disorder receiving extended-release naltrexone: A 12-week randomized controlled trial and a 36-week follow-up

INTRODUCTION

Life satisfaction (LS) in opioid-dependent individuals is lower than in the general population. This study aimed to explore changes in LS during short- and long-term treatment with extended-release naltrexone (XR-NTX).

METHODS

This open-label 12-week clinical trial randomized 159 participants to either monthly XR-NTX or daily buprenorphine-naloxone (BP-NLX). In a subsequent 36-week follow-up study on XR-NTX, participants either continued or switched to XR-NTX. The study collected data on the Temporary Satisfaction with Life (TSWL) and illicit opioid use every fourth week. The research team assessed changes in TSWL by a linear mixed model and growth mixture model. The study assessed relationship between opioid use and TSWL by a linear mixed model.

RESULTS

Change in LS differed significantly between the groups in both study periods. TSWL scores were significantly higher in the XR-NTX group at week 4 (p = 0.013) and week 8 (p = 0.002). In the follow-up period, the groups were significantly different only at week 16 (p = 0.031) and week 48 (p = 0.025), with the higher TSWL scores in the XR-NTX continued group. Increase in opioid use by one day was associated with a 0.12 point lower mean TSWL score. Both study periods identified groups with low and high LS levels. In the trial period, the TSWL scores exhibited a significant increase from baseline to week 12 in both groups, p < 0.001 and p = 0.011 in the low and high LS group, respectively. In the follow-up period, the TSWL scores exhibited a significant increase from week 16 to week 48 (p = 0.003) in the high LS group, while the low LS group showed persistently lower values throughout that period.

CONCLUSIONS

XR-NTX treatment given once monthly is associated with higher LS, as measured by TSWL, compared to daily use of BP-NLX. The majority of the participants had relatively low TSWL scores and did not report any change in TSWL during longer-term treatment. The study found a significant association between more frequent illicit opioid use and a low or decreased LS during follow-up.

Characteristics and risk of incarceration among "hard-to-reach" people who use drugs: A five-year prospective cohort study combining self-reports and registry data

BACKGROUND

Incarcerations are associated with an increased risk of morbidity and mortality among people who use drugs (PWUD). In a sample of 884 PWUD, we examine and estimate the risk of incarcerations (i.e., number, duration, and most serious offense).

METHODS

In this prospective cohort study, PWUD were recruited from street- and low-threshold services in seven Norwegian cities in 2013 (Sept-Nov), and followed through the Correctional Service Registry until 20.12.2018. The risk of incarceration during follow-up was examined with multivariable logistic (no incarceration vs. at least one) and multinomial regression models ("no incarcerations", vs. "1″, "≥2″), while accounting for gender, age, homelessness/shelter use, opioid substitution treatment, illegal income sources, injecting behaviours, previous incarcerations, and recruitment city.

RESULTS

During follow-up, there were in total 662 incarceration episodes, and 44.7% of the participants were incarcerated at least once. Overall, 37.5% of those incarcerated had at least one episode due to a drug offense. The average incarceration duration was 65.2 days with 3.5% of the episodes lasting ≥one year. Gender (male), homelessness/shelter use, illegal income sources, injecting stimulants, and previous incarcerations increased the odds of incarceration, while older age decreased the odds. Gender (male), younger age, self-reported theft or theft and dealing, injecting stimulants or heroin and stimulants and previous incarcerations increased the risk of multiple incarcerations.

CONCLUSION

In a five-year prospective study of PWUD, incarcerations were common, and short-term sentences and recidivism were the norm. This is of concern as incarcerations add to an already elevated morbidity and mortality risk in this population.

Living a normal life? Follow-up study of women who had been in opioid maintenance treatment during pregnancy

BACKGROUND

There are few longitudinal follow-up studies of patients in opioid maintenance treatment (OMT). For this reason we performed a follow-up study of a cohort of 67 women who had used OMT-medications during pregnancy an average of ten years earlier. The aim of our study was to explore how the women were doing over time regarding OMT medication adherence and use of other legal and illegal substances, as well as to evaluate the mortality for the women and custody situation for the children in the cohort.

METHODS

Participants were recruited from two cohorts in our previous pregnancy study covering women who gave birth from 2004 to 2009. Sixty-seven women agreed to be interviewed, which is 73% of the eligible women from our original study. We developed a questionnaire, which we used in the interview, that focused primarily on these women's current life situation (custody of child they had delivered, the use of medications in OMT and other legal and illegal substances, and several other health and social aspects of the participants' lives).

RESULTS

Two women had died prior to the follow-up. Eighty-one percent of the women had custody of the child they had delivered in our pregnancy study and half the women were single parents. Fifty-four percent of the women were employed. At follow-up, 42% of the women were in methadone maintenance treatment (MMT), 39% were in buprenorphine maintenance treatment (BMT), and 19% had left OMT. One-third of the women had changed their OMT medication during the follow-up period. The majority (77%) were satisfied with their current OMT medication. The women in MMT seemed to be more severe substance dependent than the rest of the participants. There was little use of legal and illegal substances at follow-up, especially among women with custody of their child. The frequency of substance use was low. Fourteen percent of the women were in the process of leaving OMT and another half of the women wanted to leave OMT, but had no plan for how and when.

CONCLUSION

This follow-up study describes a predominantly well rehabilitated cohort of women who had given birth while in OMT ten years earlier. The majority of the women had custody of their children and used very few legal and illegal drugs. Our findings may be explained partly from a life course perspective, with the women having experienced turning points when starting OMT or becoming mothers.

Dihydrocodeine for detoxification and maintenance treatment in individuals with opiate use disorders

BACKGROUND

Medical treatment and detoxification from opiate disorders includes oral administration of opioid agonists. Dihydrocodeine (DHC) substitution treatment is typically low threshold and therefore has the capacity to reach wider groups of opiate users. Decisions to prescribe DHC to patients with less severe opiate disorders centre on its perceived safety, reduced toxicity, shorter half-life and more rapid onset of action, and potential retention of patients. This review set out to investigate the effects of DHC in comparison to other pharmaceutical opioids and placebos in the detoxification and substitution of individuals with opiate use disorders.

OBJECTIVES

To investigate the effectiveness of DHC in reducing illicit opiate use and other health-related outcomes among adults compared to other drugs or placebos used for detoxification or substitution therapy.

SEARCH METHODS

In February 2019 we searched Cochrane Drugs and Alcohol's Specialised Register, CENTRAL, PubMed, Embase and Web of Science. We also searched for ongoing and unpublished studies via ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and Trialsjournal.com. All searches included non-English language literature. We handsearched references of topic-related systematic reviews and the included studies.

SELECTION CRITERIA

We included randomised controlled trials that evaluated the effect of DHC for detoxification and maintenance substitution therapy for adolescent (aged 15 years and older) and adult illicit opiate users. The primary outcomes were abstinence from illicit opiate use following detoxification or maintenance therapy measured by self-report or urinalysis. The secondary outcomes were treatment retention and other health and behaviour outcomes.

DATA COLLECTION AND ANALYSIS

We followed the standard methodological procedures that are outlined by Cochrane. This includes the GRADE approach to appraise the quality of evidence.

MAIN RESULTS

We included three trials (in five articles) with 385 opiate-using participants that measured outcomes at different follow-up periods in this review. Two studies with 150 individuals compared DHC with buprenorphine for detoxification, and one study with 235 participants compared DHC to methadone for maintenance substitution therapy. We downgraded the quality of evidence mainly due to risk of bias and imprecision. For the two studies that compared DHC to buprenorphine, we found low-quality evidence of no significant difference between DHC and buprenorphine for detoxification at six-month follow-up (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.25 to 1.39; P = 0.23) in the meta-analysis for the primary outcome of abstinence from illicit opiates. Similarly, low-quality evidence indicated no difference for treatment retention (RR 1.29, 95% CI 0.99 to 1.68; P = 0.06). In the single trial that compared DHC to methadone for maintenance substitution therapy, the evidence was also of low quality, and there may be no difference in effects between DHC and methadone for reported abstinence from illicit opiates (mean difference (MD) -0.01, 95% CI -0.31 to 0.29). For treatment retention at six months' follow-up in this single trial, the RR calculated with an intention-to-treat analysis also indicated that there may be no difference between DHC and methadone (RR 1.04, 95% CI 0.94 to 1.16). The studies that compared DHC to buprenorphine reported no serious adverse events, while the DHC versus methadone study reported one death due to methadone overdose.

AUTHORS' CONCLUSIONS

We found low-quality evidence that DHC may be no more effective than other commonly used pharmacological interventions in reducing illicit opiate use. It is therefore premature to make any conclusive statements about the effectiveness of DHC, and it is suggested that further high-quality studies are conducted, especially in low- to middle-income countries.

Association between opioid use disorder and fractures: a population-based study

AIMS

To test whether fractures and osteoporosis are more prevalent among patients with opioid use disorder (OUD) than patients without OUD in Taiwan.

DESIGN

We conducted a retrospective cohort study using data from the National Health Insurance Research Database (NHIRD) in Taiwan.

SETTING

Taiwan.

PARTICIPANTS

The number of adult patients with OUD and without OUD was 3695 and 14 780, respectively. We established both cohorts from 1 January 1998 to 31 December 2011 to observe the incidence of fracture. The occurrence of fracture was followed-up until the end of 2011.

MEASUREMENTS

The primary measure was incidence of fracture. The relative risk of fracture was estimated using the Cox proportional hazard model after adjusting for age, sex, index year and comorbidities. Comorbidities included diabetes mellitus, hyperlipidemia, stroke, chronic obstructive pulmonary disease, heart failure, alcohol-related illness, osteoporosis, end-stage renal disease, obesity and rheumatoid arthritis, using the International Classification of Diseases, 9th revision, clinical modification.

FINDINGS

Patients with OUD were 4.13 times more likely to suffer fractures than patients without OUD [incidence rate (IR) per 1000 person-years = 23.0 versus 5.47, adjusted hazard ratio (HR) = 3.74, 95% confidence interval (CI) = 3.27-4.29]. Compared with the control group, the risk of fracture was higher among the patients with OUD. Risk of fracture was higher in male elderly patients with diabetes mellitus, alcohol-related illness or osteoporosis. The cumulative incidences of fracture over 14 years of patients with OUD and without OUD differed significantly.

CONCLUSIONS

Taiwanese patients with opioid use disorder appear to have a higher adjusted hazard ratio for fracture than Taiwanese patients without opioid use disorder.

The clinical consequences of variable selection in multiple regression models: a case study of the Norwegian Opioid Maintenance Treatment program

Background: Selecting which variables to include in multiple regression models is a pervasive problem in medical research.Objectives: Based on questionnaire data (n = 18538, 69.9% men) from the Norwegian Opioid Maintenance Treatment Program, this study aims to compare the performance of different variable selection methods and the potential clinical consequences of choice of method. The effect of missing data is also explored.Methods: The dependent variable was engagement in criminal behavior while in treatment. Twenty-nine potential covariates on demographics, psychosocial factors and drug use were tested for inclusion in a multiple logistic regression model. Both complete case and multiply imputed data were considered. We compared the results from variable selection methods ranging from expert-based and purposeful variable selection, through stepwise methods, to more recently developed penalized regression using the Least Absolute Shrinkage and Selection Operator (LASSO).Results: The various variable selection methods resulted in regression models including from 9 to 22 covariates. The stepwise selection procedures generated the models with the most covariates included. The choice of variable selection method directly affected the estimated regression coefficients, both in effect size and statistical significance. For several variables the expert-based approach disagreed with all data-driven methods.Conclusions: The choice of variable selection method may strongly affect the resulting regression model, along with accompanying effect sizes and confidence intervals. This may affect clinical conclusions. The process should consequently be given sufficient consideration in model building. We recommend combining expert knowledge with a data-driven variable selection method to explore the models' robustness.

Polluting pharmaceutical atmospheres: Compulsion, resistance, and symbolism of buprenorphine in Norway

This article offers a counter narrative to the current ethnographic studies on treatment with buprenorphine, in which notions of promised and experienced normality dominate. In some countries, introduction of buprenorphine led to a perceived “normalisation” of opioid substitution treatment, and this new modality was well received. However, in Norway the response has been almost the opposite: patients have reacted with feelings of disenfranchisement, failure, and mistrust. Based on ethnographic fieldwork in Norway, this article offers comparative insight into local experiences and subjectivities in the context of the globalisation of buprenorphine. By outlining the ethnographic description of the pharmaceutical atmosphere of forced transfers to buprenorphine-naloxone, I show that the social history of the medication is as significant as its pharmacological qualities for various treatment effects. An analysis of the reactions to this treatment modality highlights the reciprocal shaping of lived experiences and institutional forces surrounding pharmaceutical use in general and opioids in particular.

How handling missing data may impact conclusions: A comparison of six different imputation methods for categorical questionnaire data

Objectives:

Missing data is a recurrent issue in many fields of medical research, particularly in questionnaires. The aim of this article is to describe and compare six conceptually different multiple imputation methods, alongside the commonly used complete case analysis, and to explore whether the choice of methodology for handling missing data might impact clinical conclusions drawn from a regression model when data are categorical.

Methods:

In addition to the commonly used complete case analysis, we tested the following six imputation methods: multiple imputation using expectation–maximization with bootstrapping, multiple imputation using multiple correspondence analysis, multiple imputation using latent class analysis, multiple hot deck imputation and multivariate imputation by chained equations with two different model specifications: logistic regression and random forests. The methods are tested on real data from a questionnaire-based study in the Norwegian opioid maintenance treatment programme.

Results:

All methods performed relatively well when the sample size was large (n = 1000). For a smaller sample size (n = 200), the regression estimates depend heavily on the level of missing. When the amount of missing was ⩾20%, in particular, complete case analysis, hot deck and random forests had biased estimates with too low coverage. Multiple imputation using multiple correspondence analysis had the best performance all over.

Conclusion:

The choice of missing handling methodology has a significant impact on the clinical interpretation of the accompanying statistical analyses. With missing data, the choice of whether to impute or not, and choice of imputation method, can influence clinical conclusion drawn from a regression model and should therefore be given sufficient consideration.

Opioid tapering in patients with prescription opioid use disorder: A retrospective study

BACKGROUND AND AIMS

Opioid use disorder (OUD) refers to a maladaptive pattern of opioid use leading to clinically significant impairment or distress. OUD causes, and vice versa, misuses and abuse of opioid medications. Clinicians face daily challenges to treat patients with prescription opioid use disorder. An evidence-based management for people who are already addicted to opioids has been identified as the national priority in the US; however, options are limited in clinical practices. In this study, we aimed to explore the success rate and important adjuvant medications in the medication assisted treatment with temporary use of methadone for opioid discontinuation in patients with prescription OUD.

METHODS

This is a retrospective chart review performed at a private physician office for physical medicine and rehabilitation. We reviewed all medical records dated between December 1st, 2011 and August 30th, 2016. The initial evaluation of the included patients (N=140) was completed between December 1st, 2011 and December 31st, 2014. They all have concumittant prescription OUD and chronic non-cancer pain. The patients (87 female and 53 male) were 46.7±12.7 years old, and had a history of opioid use of 7.7±6.1 years. All patients received the comprehensive opioid taper treatments (including interventional pain management techniques, psychotherapy, acupuncture, physical modalities and exercises, and adjuvant medications) on top of the medication assisted treatment using methadone (transient use). Opioid tapering was considered successful when no opioid medication was used in the last patient visit.

RESULTS

The 140 patients had pain of 9.6±8.4 years with 8/10 intensity before treatment which decreased after treatment in all comparisons (p<0.001 for all). Opioids were successfully tapered off in 39 (27.9%) patients after 6.6±6.7 visits over 8.8±7.2 months; these patients maintained opioid abstinence over 14.3±13.0 months with regular office visits. Among the 101 patients with unsuccessful opioid tapering, 13 patients only visited the outpatient clinic once. Significant differences were found between patients with and without successful opioid tapering in treatment duration, number of clinic visits, the use of mirtazepine, bupropion, topiramate, and trigger point injections with the univariate analyses. The use of mirtazepine (OR, 3.75; 95% CI, 1.48-9.49), topiramate (OR, 5.61; 95% CI, 1.91-16.48), or bupropion (OR, 2.5; 95% CI, 1.08-5.81) was significantly associated with successful opioid tapering. The associations remain significant for mirtazepine and topiramate (not bupropion) in different adjusted models.

CONCLUSIONS

With comprehensive treatments, 27.9% of patients had successful opioid tapering with opioid abstinence for over a year. The use of mirtazepine, topiramate, or likely bupropion was associated with successful opioid tapering in the medication assisted treatment with temporary use of methadone. Opioid tapering may be a practical option and should be considered for managing prescription OUD.

IMPLICATIONS

For patients with OUD, indefinite opioid maintenance treatment may not be necessary. Considering the ethical values of autonomy, nonmaleficence, and beneficence, clinicians should provide patients with OUD the option of opioid tapering.

High risk of overdose death following release from prison: variations in mortality during a 15-year observation period

BACKGROUND AND AIMS

The time post-release from prison involves elevated mortality, especially overdose deaths. Variations in overdose mortality both by time since release from prison and time of release has not been investigated sufficiently. Our aims were to estimate and compare overdose death rates at time intervals after prison release and to estimate the effect on overdose death rates over calendar time.

DESIGN, SETTING, PARTICIPANTS, MEASUREMENTS

This 15-year cohort study includes all individuals (n = 91 090) released from prison (1 January 2000 to 31 December 2014) obtained from the Norwegian prison registry, linked to the Norwegian Cause of Death Registry (2000-14). All-cause and cause-specific mortality were examined during different time-periods following release: first week, second week, 3-4 weeks and 2-6 months, and by three different time intervals of release. We calculated crude mortality rates (CMRs) per 1000 person-years and estimated incidence rate ratios (IRR) by Poisson regression analysis adjusting for time intervals after prison release, release periods and time spent in prison.

FINDINGS

Overdose deaths accounted for 85% (n = 123) of all deaths during the first week following release (n = 145), with a peak during the 2 days immediately following release. Compared with week 1, the risk of overdose death was more than halved during week 2 [IRR = 0.43; 95% confidence interval (CI) = 0.31-0.59] and reduced to one-fifth in weeks 3-4 (IRR = 0.22; 95% CI = 0.16-0.31). The risk of overdose mortality during the first 6 months post-release was almost twofold higher in 2000-04 compared with 2005-09 (IRR = 0.53; 95% CI = 0.43-0.65) and 2010-14 (IRR = 0.47; 95% CI = 0.37-0.59). The risk of overdose death was highest for those incarcerated for 3-12 months compared with those who were incarcerated for shorter or longer periods, and recidivism was associated with risk of overdose death.

CONCLUSIONS

There is an elevated risk of death from drug overdose among individuals released from Norwegian prisons, peaking in the first week. The risk has reduced since 2000-04, but is greatest for those serving 3-12 months compared with shorter or longer periods.

Pharmacokinetic Evaluation of Once-Weekly and Once-Monthly Buprenorphine Subcutaneous Injection Depots (CAM2038) Versus Intravenous and Sublingual Buprenorphine in Healthy Volunteers Under Naltrexone Blockade: An Open-Label Phase 1 Study

INTRODUCTION

CAM2038 q1w (once weekly) and q4w (once monthly) are investigational buprenorphine subcutaneous (SC) formulations based on FluidCrystal^® injection depot technology. These two drug products are being developed for opioid dependence treatment, with a target for once-weekly and once-monthly SC dosing. The rationale for developing two products with different dosing frequencies is that treatment strategies/routines, and hence different treatment preferences, can vary between patients, different stages of opioid maintenance treatment, and countries. This study evaluated the pharmacokinetics and safety of buprenorphine and norbuprenorphine following administration of CAM2038 q1w or q4w versus active controls.

METHODS

Healthy volunteers were randomized to five treatment groups. All received a single intravenous dose of buprenorphine 600 µg, followed post-washout by a single dose of CAM2038 q4w 96 mg, a single dose of CAM2038 q4w 192 mg, or sublingual buprenorphine 8, 16, or 24 mg daily for 7 days, followed post-washout by a single dose of CAM2038 q4w 64 or 128 mg or four repeated weekly doses of CAM2038 q1w 16 mg. All subjects received daily naltrexone.

RESULTS

Eighty-seven subjects were randomized. Median buprenorphine t _max after CAM2038 q4w was 4-10 h (24 h for CAM2038 q1w); mean terminal half-life was 19-25 days (5 days for CAM2038 q1w). CAM2038 q4w showed dose-proportional buprenorphine release, with similar exposure to repeat-dose CAM2038 q1w at comparable monthly dose level. Both CAM2038 formulations showed complete absolute bioavailability of buprenorphine and 5.7- to 7.7-fold greater buprenorphine bioavailability versus sublingual buprenorphine. CAM2038 q1w and q4w were well tolerated; subjects' acceptance was higher for CAM2038 than for sublingual buprenorphine 1 h post-dose.

CONCLUSIONS

The pharmacokinetic profiles of CAM2038 q1w and q4w versus sublingual buprenorphine support expected treatment efficacy with once-weekly and once-monthly dosing, respectively. CAM2038 formulations were safe and showed good local tolerability.

TRIAL REGISTRATION

ISRCTN24987553.

FUNDING

Camurus AB.

A Comparison of Reinforcement Based Treatment (RBT) versus RBT plus Recovery Housing (RBTRH)

OBJECTIVES

Reinforcement-based treatment (RBT) plus recovery housing (RBT^RH) improves outcomes for individuals with opioid use disorders. No studies have examined the efficacy of RBT in the absence of abstinent-contingent housing.

METHODS

We compared highly similar participants from a study of outpatient RBT (RBT, n=55) and the RBT^RH (n=80) arm of a randomized trial wherein participants received abstinent-contingent payment for recovery housing sponsored by the research program. Abstinence and employment outcomes were assessed at one, three, and six months. Regression was used to identify predictors of abstinence. Sensitivity analyses explored the impact of housing on outcomes.

RESULTS

RBT and RBT^RH participants had similar abstinence and employment outcomes. Predictors of abstinence in the sample included recovery housing residence and employment. However, a distinct RBT sub-group emerged, as 33% of the sample accessed self-pay RH (RBT^SPRH). Sensitivity analyses compared the two RH groups (self-pay and program-supported) to RBT outpatient treatment (RBT). The RBT^SPRH and RBT^RH groups had similar abstinence outcomes, and both groups had superior abstinence outcomes compared to RBT. The RBT^SPRH group had the most sustained effects relative to RBT, including higher abstinence rates, and more favorable employment outcomes at six months (ps<.05). The RBT^SPRH group reported more days of employment compared to both the RBT and RBT^RH groups at three months (ps<.05).

CONCLUSIONS

Findings highlight the importance of recovery housing for promoting improved outcomes among RBT participants. Research is needed to explore the aspects of recovery housing versus outpatient treatment that are associated with improved outcomes in the population.

Access to Addiction Pharmacotherapy in Private Health Plans

BACKGROUND

An increasing number of medications are available to treat addictions. To understand access to addiction medications, it is essential to consider the role of private health plans. To contain medication expenditures, most U.S. health plans use cost-sharing and administrative controls, which may impact physicians' prescribing and patients' use of addiction medications. This study identified health plan approaches to manage access to and utilization of addiction medications (oral and injectable naltrexone, acamprosate, and buprenorphine).

METHODS

Data are from a nationally representative survey of private health plans in 2010 (n=385 plans, 935 products; response rate 89%), compared to the same survey in 2003. The study assessed formulary inclusion, prior authorization, step therapy, overall restrictiveness, and if and how health plans encourage pharmacotherapy.

RESULTS

Formulary exclusions were rare in 2010, with acamprosate excluded most often, by only 9% of products. Injectable naltrexone was covered by 96% of products. Prior authorization was common for injectable naltrexone (85%) and rare for acamprosate (3%). Step therapy policies were used only for injectable naltrexone (41%) and acamprosate (20%). Several medications were often on the most expensive tier. Changes since 2003 include fewer exclusions, yet increased use of other management approaches. Most health plans encourage use of addiction pharmacotherapy, and use a variety of methods to do so.

CONCLUSIONS

Management of addiction medications has increased over time but it is not ubiquitous. However, health plans now also include all medications on formularies and encourage providers to use them, indicating that they value addiction pharmacotherapy as an evidence-based practice.

Opioid substitution therapy: Lowering the treatment thresholds

BACKGROUND

Opioid substitution therapy (OST) has been established as the gold standard in treating opioid use disorders. Nevertheless, there is still a debate regarding the qualitative characteristics that define the optimal OST intervention, namely the treatment threshold. The aim of this review is twofold: first, to provide a summary and definition of "treatment thresholds", and second, to outline these thresholds and describe how they related to low and high threshold treatment characteristics and outcomes.

METHOD

We searched the main databases of Medline, PubMed, PsycInfo, EMBASE, CINAHL and the Cochrane Library. Original published research papers, reviews, and meta-analyses, containing the eligible keywords: "opioid substitution", "OST", "low threshold", "high threshold" were searched alone and in combination, up to June, 2015.

RESULTS

Treatment thresholds were defined as barriers a patient may face prior to and during treatment. The variables of these barriers were classified into treatment accessibility barriers and treatment design barriers. There are increasing numbers of studies implementing low threshold designs with an increasing body of evidence suggesting better treatment outcomes compared to high threshold designs.

CONCLUSION

Clinical characteristics of low threshold treatments that were identified to increase the effectiveness of OST intervention include increasing accessibility so as to avoid waiting lists, using personalized treatment options regarding medication choice and dose titration, flexible treatment duration, a treatment design that focuses on maintenance and harm reduction with emphasis on the retention of low adherence patients.

Breaking the addictive cycle of the system: improving US criminal justice practices to address substance use disorders

PURPOSE

Recent political commentary in the USA has suggested that there is great potential for current criminal justice practices designed for drug-involved offenders to be significantly overhauled in the near future. It is imperative to plan for these changes by assessing how well current programs serve drug-involved criminal justice populations. The paper aims to discuss these issues.

DESIGN/METHODOLOGY/APPROACH

This critical assessment begins with an overview of the most recent research on the prevalence and impact that substance use disorders have within the criminal justice system. Although the evidence demonstrates that relying on incarceration as a crime control method for drug-involved offenders has many shortcomings, there are innovative new programs being adopted across the country. Two of these promising programs are discussed, as well as the potential results that could be realized from integrating medication assisted treatment into appropriate criminal justice programs designed for drug-involved offenders.

FINDINGS

Incarceration is a failed practice for attending to the underlying reasons why many drug-involved offenders become involved in criminal activities. There are encouraging new programs emerging in different parts of the USA, but the inclusion of supplemental treatment options could further promote positive outcomes.

ORIGINALITY/VALUE

The impending expansion of criminal justice programs for drug-involved offenders must consider how innovative new programs can be fused with supplemental treatment options to achieve the best results.

Are overdoses treated by ambulance services an opportunity for additional interventions? A prospective cohort study

AIMS

To assess whether people who inject drugs (PWID) and who are treated for overdose by ambulance services have a greater mortality risk compared with other PWID, and to compare mortality risk within potentially critical time-periods (1 week, 1 month, 3 months, 6 months, 1 year, 5 years) after an overdose attendance with the mortality risk within potentially non-critical time-periods (time before and/or after critical periods).

DESIGN

A prospective cohort study.

SETTING

Oslo, Norway.

PARTICIPANTS

A total of 172 PWID street-recruited in 1997 and followed-up until the end of 2004.

MEASUREMENTS

Interview data linked to data from ambulance records, Norwegian Correctional Services, Opioid Substitution Treatment records and National Cause of Death Registry. Separate Cox regression models (one for each critical time-period) were estimated.

FINDINGS

Ambulance services treated 54% of the participants for an overdose during follow-up. The mortality rate was 2.8 per 100 person-years for those with an overdose and 3.3 for those without; the adjusted hazard ratio (HR) was 1.3 (95% CI = 0.6, 2.6, P = 0.482). Mortality risk was greater in all but the shortest critical time-period following ambulance attendance than in the non-critical periods. The mortality risk remained significantly elevated during critical periods, even when adjusted for total time spent in prison and substitution treatment. The HR ranged from 9.4 (95% CI = 3.5, 25.4) in the month after an overdose to 13.9 (95% CI = 6.4, 30.2) in the 5-year period.

CONCLUSIONS

Mortality risk among people who inject drugs is significantly greater in time-periods after an overdose attendance than outside these time-periods.

New methadone formulation in France: results from 5 years of utilization

BACKGROUND

In France, methadone has historically been less accessible than buprenorphine. In 2008, a dry formulation (capsule) was introduced into the market, aimed in particular to improve methadone accessibility.

OBJECTIVE

To describe the impact (prevalence of use, patient profiles and compliance with requirements) of the dry methadone formulation in France.

METHOD

A retrospective cohort (from 2008 to 2012) was created from the data of the French General Health Insurance System which covers 80% of the French population. For each years, all subjects affiliated to this insurance system in southeast France (about 8.5 million inhabitants) with at least two reimbursements of methadone between 1st January and 31st December were selected.

RESULTS

In 2012, the proportion of capsule users was almost the same as that of syrup users (40.0% versus 43.1%; p < 0.001). The rise in the number of methadone users has followed the rise in capsule users. Over the study period, the proportion of patients using benzodiazepines or antidepressants was 6-9% (p < 0.001) higher for capsule users than for syrup users. On average over the study period, 18% of subjects had at least one concurrent issue of the two forms.

CONCLUSION

The study has shown the rapid spread of the capsule formulation among methadone users. This may suggest that the capsule is well accepted by patients and the medical community. However, the monitoring of methadone-related deaths should continue because of the pharmacodynamic properties of methadone and the context of relaxed regulations concerning access to methadone maintenance treatement (MMT).

Prescription Opioids in Pregnancy and Birth Outcomes: A Review of the Literature

Prescription opioids are used prenatally for the management of pain, as well as for opiate dependency. Opioids are known to cross the placenta and despite the evidence of possible adverse effects on fetal development, studies have consistently shown prescription opioids are among the most commonly prescribed medications and the prevalence of use is increasing among pregnant women. This article summarizes the available literature documenting potential harms associated with prescription opioid use during pregnancy, including poor fetal growth, preterm birth, birth defects, and neonatal abstinence syndrome.

Illicit use of opioid substitution drugs: prevalence, user characteristics, and the association with non-fatal overdoses

BACKGROUND AND AIMS

Diversion of opioid substitution drugs (OSD) is of public concern. This study examined the prevalence, frequency, and predictors of illicit OSD use in a group of injecting drug users (IDUs) and assessed if such use was associated with non-fatal overdoses.

METHODS

Semi-annual cross-sectional interviews conducted in Oslo, Norway (2006-2013), from 1355 street-recruited IDUs. Hurdle, logistic, and multinomial regression models were employed.

RESULTS

Overall, 27% reported illicit OSD use in the past four weeks; 16.8% methadone, 12.5% buprenorphine, and 2.9% both drugs. Almost 1/10 reported at least one non-fatal overdose in the past four weeks, and roughly 1/3 reported such experience in the past year. Use of additional drugs tended to be equally, or more prevalent among illicit OSD users than other IDUs. In terms of illicit OSD use being a risk factor for non-lethal overdoses, our results showed significant associations only for infrequent buprenorphine use (using once or less than once per week). Other factors associated with non-fatal overdoses included age, education, homelessness, as well as the benzodiazepines, stimulants, and heroin use.

CONCLUSIONS

Users of diverted OSD may represent a high-risk population, as they used more additional drugs and used them more frequently than other IDUs. However, illicit OSD use may be less harmful than previously assumed. After accounting for an extensive set of covariates, only infrequent illicit buprenorphine use, but not methadone use, was associated with non-fatal overdoses.