Psychiatric comorbidities in opioid-dependent patients undergoing a replacement therapy programme in Spain: The PROTEUS study

Exploring dual diagnosis in opioid agonist treatment patients: a registry-linkage study in Czechia and Norway

BACKGROUND

Knowledge of co-occurring mental disorders (termed 'dual diagnosis') among patients receiving opioid agonist treatment (OAT) is scarce. This study aimed (1) to estimate the prevalence and structure of dual diagnoses in two national cohorts of OAT patients and (2) to compare mental disorders between OAT patients and the general populations stratified on sex and standardized by age.

METHODS

A registry-linkage study of OAT patients from Czechia (N = 4,280) and Norway (N = 11,389) during 2010-2019 was conducted. Data on mental disorders (F00-F99; ICD-10) recorded in nationwide health registers were linked to the individuals registered in OAT. Dual diagnoses were defined as any mental disorder excluding substance use disorders (SUDs, F10-F19; ICD-10). Sex-specific age-standardized morbidity ratios (SMR) were calculated for 2019 to compare OAT patients and the general populations.

RESULTS

The prevalence of dual diagnosis was 57.3% for Czechia and 78.3% for Norway. In Czechia, anxiety (31.1%) and personality disorders (25.7%) were the most prevalent, whereas anxiety (33.8%) and depression (20.8%) were the most prevalent in Norway. Large country-specific variations were observed, e.g., in ADHD (0.5% in Czechia, 15.8% in Norway), implying differences in screening and diagnostic practices. The SMR estimates for any mental disorders were 3.1 (females) and 5.1 (males) in Czechia and 5.6 (females) and 8.2 (males) in Norway. OAT females had a significantly higher prevalence of co-occurring mental disorders, whereas SMRs were higher in OAT males. In addition to opioid use disorder (OUD), other substance use disorders (SUDs) were frequently recorded in both countries.

CONCLUSIONS

Results indicate an excess of mental health problems in OAT patients compared to the general population of the same sex and age in both countries, requiring appropriate clinical attention. Country-specific differences may stem from variations in diagnostics and care, reporting to registers, OAT provision, or substance use patterns.

Effect of integrated hepatitis C virus treatment on psychological distress in people with substance use disorders

People with substance use disorders (SUD) have a high prevalence of chronic hepatitis C virus (HCV) infection and mental health disorders. We aimed to assess the impact of integrated HCV treatment on psychological distress measured by Hopkins-symptom-checklist-10 (SCL-10). This multi-center randomized controlled trial evaluated psychological distress as a secondary outcome of integrated HCV treatment (INTRO-HCV trial). From 2017 to 2019, 289 participants were randomly assigned to receive either integrated or standard HCV treatment with direct-acting antiviral therapy. Integrated HCV treatment was delivered in eight decentralized outpatient opioid agonist therapy clinics and two community care centers; standard treatment was delivered in internal medicine outpatient clinics at centralized hospitals. Participants in the integrated treatment arm had a sustained virologic response of 93% compared to 73% for those in standard treatment arm. Psychological distress was assessed using SCL-10 prior to initiation of HCV treatment and 12 weeks after treatment completion. The mean SCL-10 score prior to HCV treatment was 2.2 (standard deviation [SD]: 0.7) for patients receiving integrated HCV treatment and 2.2 (SD: 0.8) for those receiving standard HCV treatment. Twelve weeks after the end of treatment, the mean SCL-10 score change was - 0.1 (- 0.3;0.0) in the integrated compared to the standard arm. Psychological distress did not substantially change during the treatment period and was not significantly different between the treatment arms.

Attention-deficit/hyperactivity disorder (ADHD) symptoms and their relation to diagnosed ADHD, sociodemographic characteristics, and substance use among patients receiving opioid agonist therapy: a Norwegian cohort study

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) symptoms may challenge sufficient treatment of substance use and mental disorders. The literature on the extent of such symptoms among patients receiving opioid agonist therapy (OAT) is scarce. This study examined ADHD symptoms using the ADHD self-report scale (ASRS) and the association between the 'ASRS-memory' and 'ASRS-attention' scores and substance use and sociodemographic characteristics among patients receiving OAT.

METHODS

We used data from assessment visits of a cohort of patients in Norway. In total, 701 patients were included from May 2017 to March 2022. All patients responded at least once to two ASRS questions assessing memory and attention, respectively. Ordinal regression analyses were performed to investigate whether the two obtained scores were associated with age, sex, frequent substance use, injecting use, housing status, and educational attainment at baseline, i.e., the first assessment, and over time. The results are presented as odds ratios (OR) with 95% confidence intervals (CI). Additionally, a subsample of 225 patients completed an extended interview, including the ASRS-screener and collection of registered mental disorder diagnoses from the medical records. Standard cutoffs were used to define the presence of each ASRS symptom or a positive ASRS-screener ('ASRS-positive').

RESULTS

At baseline, 428 (61%) and 307 (53%) patients scored over the cutoffs on the 'ASRS-memory' and 'ASRS-attention,' respectively. Frequent cannabis use was associated with higher 'ASRS-memory' (OR: 1.7, 95% CI: 1.1-2.6) and 'ASRS-attention' (1.7, 1.1-2.5) scores compared with less or no use at baseline, though reduced score on the 'ASRS-memory' over time (0.7, 0.6-1.0). At baseline, frequent stimulant use (1.8, 1.0-3.2) and low educational attainment (0.1, 0.0-0.8) were associated with higher 'ASRS-memory' scores. In the subsample fulfilling the ASRS-screener, 45% of the patients were 'ASRS-positive,' of whom 13% with a registered ADHD diagnosis.

CONCLUSIONS

Our findings illustrate a relationship between the ASRS-memory and -attention scores and frequent cannabis and stimulant use. Furthermore, nearly half of the subsample was 'ASRS-positive.' Patients receiving OAT might benefit from being further assessed for ADHD, but improved diagnostic methods are required.

Patients with severe mental illness and hepatitis C virus infection benefit from new pangenotypic direct-acting antivirals: Results of a literature review

INTRODUCTION

Hepatitis C virus (HCV) infection is a global health problem that can results in cirrhosis, hepatocellular carcinoma and even death. HCV infection is 3-20-fold more prevalent among patients with versus without severe mental illness (SMI), such as major depressive disorder, personality disorder, bipolar disorder and schizophrenia. Treatment options for HCV were formerly based on pegylated interferon alpha, which is associated with neuropsychiatric adverse events, and this contributed to the exclusion of patients with SMI from HCV treatment, elimination programmes, and clinical trials. Moreover, the assumption of poor adherence, scant access to healthcare and the stigma and vulnerability of this population emerged as barriers and contributed to the low rates of treatment and efficacy.

METHODS

This paper reviews the literature published between December 2010 and December 2020 exploring the epidemiology of HCV in patients with SMI, and vice versa, the effect of HCV infection, barriers to the management of illness in these patients, and benefits of new therapeutic options with pangenotypic direct antiviral agents (DAAs).

RESULTS

The approval of DAAs has changed the paradigm of HCV infection treatment. DAAs have proven to be an equally efficacious and safe option that improves quality of life (QoL) in patients SMI.

CONCLUSIONS

Knowledge of the consequences of the HCV infection and the benefits of treatment with new pangenotypic DAAs among psychiatrists can increase screening, referral and treatment of HCV infection in patients with SMI.

Healthcare seeking among Swedish patients in opioid substitution treatment – a mixed methods study on barriers and facilitators

Background

Patients in opioid substitution treatment (OST) have poorer health than the general population. Thus, they do not seek somatic health care to the extent that is medically motivated. Barriers hindering patients from seeking medical help through the conventional healthcare system result in a high degree of unmet healthcare needs. Barriers to, and facilitators of, OST patients’ healthcare seeking have been sparsely examined.

Methods

Mixed methods were employed. The quantitative part consisted of a cross-sectional questionnaire covering questions on physical health, healthcare seeking, and barriers thereof, which was collected from 209 patients in OST. A sub-sample of eleven OST patients participated in semi-structured interviews, for the qualitative part of the study, covering experience of healthcare, lifestyle, and self-images, expectations, and ideals of Swedish healthcare.

Results

Confirmed by qualitative data, quantitative data revealed deprioritization, fear of stigma and of being treated badly, and problems in navigation throughout the healthcare system, leading to unsuccessful establishment of contact, being most common reasons for not seeking somatic healthcare. Thus, interviewees provided a deeper knowledge of the barriers stigma, lack of means to prioritize health and difficulties navigating throughout the healthcare system, leading to resignation and deprioritization. On-site primary healthcare (PHC) seemed to contribute to increased access and utilization of healthcare.

Conclusion

Individual and structural barriers decreasing access to healthcare lead to increased inequalities in healthcare utilization, adding to an already deteriorating health of this ageing population. Integration of on-site primary healthcare and OST could provide acceptable and accessible healthcare.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-022-00434-w.

New Psychoactive Substances Consumption in Opioid-Use Disorder Patients

Simple Summary

We applied a toxicological screening on 187 urine samples collected from patients with opioid-use disorder treated with opioid agonists in Barcelona and Badalona addiction care services, Spain. We found that 27.3% of urine samples were positive for any type of new psychoactive substance and 8.6% of samples were positive for a new synthetic opioid (NSO). These results show a new trend of consumption in patients with opioid-use disorder that requires social and political actions to stem associated health threats.

Abstract

(1) Background: Since the beginning of the 21st century, the large number and wide chemical variety of new psychoactive substances (NPS) that enter the market every year has become a public health problem. Given the rapidity with which the drug market is changing, many NPS are not clinically investigated and their effects and health risks are unknown. Drug testing is a very useful tool for this purpose, but, unfortunately, it is not very widespread in individuals with opioid-use disorder under detoxification treatment. The aim of this study is to investigate the use of illicit drugs and NPS in opioid-use disorder (OUD) patients on opioid agonist treatment. (2) Methods: A multicenter, descriptive, cross-sectional study was conducted at two addiction care services in Barcelona and Badalona, Spain. Urine samples were collected from OUD individuals attending these two centers, who anonymously donated a urine sample at the time of a periodical visit. Samples were analyzed by high-sensitivity gas chromatography-mass spectrometry (GC-MS) and ultra-high-performance liquid chromatography-high –resolution mass spectrometry (UHPLC-HRMS). (3) Results: Out of the 187 collected and analyzed urine samples, 27.3% were positive for any type of NPS and 8.6% were positive for new synthetic opioids, including fentanyl and its derivatives (NSO). Other frequently detected substances were benzodiazepines in 46.0% of samples, antipsychotics in 27.8% of samples, or cocaine and cannabis in 23.5% of samples. (4) Conclusion: A wide number of NPS, including NSO, have been detected in urine samples from an OUD population. A lack of NPS detection in standard drug screening among drug users can hide the identification of a potential public health problem.

Perception of a New Prolonged-Release Buprenorphine Formulation in Patients with Opioid Use Disorder: The PREDEPO Study

AIM

The aim of the study was to assess the acceptance of patients with opioid use disorder (OUD) to switching their opioid dependence treatment (ODT) for a prolonged-release buprenorphine (PRB) injection according to their prior ODT (buprenorphine/naloxone [B/N] or methadone).

METHODS

This was an observational, retrospective/cross-sectional, multicentre study of adult patients diagnosed with OUD on ODT. Data collected from diaries were analysed to know their interest and opinion on PRB. Questions with fixed response options were included, and several Likert scales were used.

RESULTS

A total of 98 patients were enrolled (B/N: 50.0%, methadone: 50.0%). The mean age was 46.9 ± 8.43 years and 79.6% were males. PRB was similarly perceived by both groups in most variables analysed, receiving a mean score of 7.2/10 (B/N: 7.4, methadone: 7.0; p = 0.520), and approximately 65% of patients said they were willing to switch to PRB (B/N: 63.3%, methadone: 65.3%; p = 0.833). Of these, a higher percentage in the B/N group considered that switching would be easy/very easy (B/N: 90.3%, methadone: 46.9%; p < 0.001) and that they would start PRB when available (B/N: 64.5%, methadone: 34.3%; p = 0.005). More than 90% would prefer the monthly injection (B/N: 93.6%, methadone: 100%; p = 0.514). One-third of patients in both groups were unsure/would not switch their ODT to PRB (B/N: 36.7%, methadone: 34.7%; p = 0.833). The main reason was administration by injection.

CONCLUSION

Two-thirds of patients would switch their treatment for PRB, and most patients on B/N considered that switching would be easy. PRB could be a suitable alternative for OUD management.

A review of sleep disturbance in adults prescribed medications for opioid use disorder: potential treatment targets for a highly prevalent, chronic problem

BACKGROUND

Sleep disturbance in individuals prescribed medications for opioid use disorder (MOUD) is common, though the nature and progression of such concerns are difficult to discern due to differing terminology and assessment type between studies. Accurately identifying and treating sleep problems in this growing population has the potential to improve comorbidity and other MOUD outcomes.

OBJECTIVE

The aim of the present review is to provide an overview of sleep in individuals stabilized on MOUD. Specifically, the following aspects of sleep were reviewed: 1) prevalence of clinically significant sleep disturbance; 2) sleep disturbance compared to findings in those not prescribed MOUD; 3) correlates of sleep disturbance; 4) self-reported sleep compared to objective measures.

METHOD

Studies were identified using 6 large databases and included if they contained at least one measure of sleep during MOUD treatment as usual. Studies were excluded if they were case studies, not available in English, or participants were in withdrawal or detoxification.

RESULTS

Forty-two studies were included and categorized by type of sleep assessment: validated self-report questionnaire; provider-assessed; polysomnography; multi-method. Correlates were included if they were statistically significant (generally p < 0.05).

CONCLUSIONS

This review indicates there is a high prevalence of chronic self-reported sleep disturbance (eg, insomnia symptoms) in this population and suggests quantitative sleep parameters (eg, total sleep time) and respiratory problems during sleep are worse than in the general population. These sleep problems are correlated with psychiatric comorbidity and other substance use. Other correlates (eg, sociodemographic factors) require further study to draw definitive conclusions.

Assessment of Subjective Sleep Problems in Men With Opioid Dependence Maintained on Buprenorphine

OBJECTIVES

To assess the rates of sleep disturbances in male patients with opioid dependence maintained on buprenorphine and to assess the factors associated with sleep disturbances in this population.

METHODS

Observational, cross-sectional study. Male patients with opioid dependence aged 18 years and older, and started on buprenorphine at least 6 months before were screened. Those with history of comorbid psychiatric illnesses (except sleep disorders), on any other substance in high-risk category (based on WHO-Alcohol Smoking Substance Involvement Screening Test (ASSIST)), or on any other psychotropic medications (in addition to OAT with buprenorphine) were excluded. Sleep was assessed using the Pittsburgh Sleep Quality Index (PSQI), Sleep-50, and Epworth Sleepiness Scale (ESS). Each participant was interviewed in a single session lasting 60 minutes.

RESULTS

One hundred six participants were included. Their mean age was 41.1 (SD 14.3) years. The participants had been on OAT with buprenorphine for a median duration of 60 months (IQR 17-120), with excellent adherence rate in past 1 month. The mean current dose of buprenorphine was 10.2 (SD 3.8) mg per day. The mean subjective total sleep time was 403.5 minutes (SD 94.8) and the median sleep latency was 35 minutes (IQR 18.8-62.5). The mean PSQI score was 6.6 (SD 3.4). Nearly 63% (n = 67) participants had PSQI scores more than 5 (PSQI > 5) suggesting sleep problems. Sociodemographic, substance use, and treatment variables were compared between participants who scored more than 5 and those who scored less than 5 on PSQI. No significant difference was found between the 2 groups.

CONCLUSIONS

Substantial proportion of male patients with opioid dependence maintained on buprenorphine have sleep problems. The sleep problems in buprenorphine-maintained patients seem to be independent of substance use and treatment-related attributes.

Treatment of opioid use disorder in primary care

Opioid use disorder (OUD) is a common, treatable chronic disease that can be effectively managed in primary care settings. Untreated OUD is associated with considerable morbidity and mortality-notably, overdose, infectious complications of injecting drug use, and profoundly diminished quality of life. Withdrawal management and medication tapers are ineffective and are associated with increased rates of relapse and death. Pharmacotherapy is the evidence based mainstay of OUD treatment, and many studies support its integration into primary care settings. Evidence is strongest for the opioid agonists buprenorphine and methadone, which randomized controlled trials have shown to decrease illicit opioid use and mortality. Discontinuation of opioid agonist therapy is associated with increased rates of relapse and mortality. Less evidence is available for the opioid antagonist extended release naltrexone, with a meta-analysis of randomized controlled trials showing decreased illicit opioid use but no effect on mortality. Treating OUD in primary care settings is cost effective, improves outcomes for both OUD and other medical comorbidities, and is highly acceptable to patients. Evidence on whether behavioral interventions improve outcomes for patients receiving pharmacotherapy is mixed, with guidelines promoting voluntary engagement in psychosocial supports, including counseling. Further work is needed to promote the integration of OUD treatment into primary care and to overcome regulatory barriers to integrating methadone into primary care treatment in the US.

Evaluation of functional status among patients undergoing maintenance treatments for opioid use disorders

Background

Methadone and buprenorphine are the most prevalent types of opioid maintenance programs in Andalusia. The main objective is comparing the functional status of patients with pharmacological opioid maintenance treatments according to different socio-demographic characteristic, health and disabilities domains and sexual difficulties.

Methods

A total of 593 patients from the Andalusia community, 329 were undergoing methadone treatment and 264 were undergoing buprenorphine treatment. The patients were interviewed by socio-demographic and opioid-related variables, assessed by functioning, disability and health domains (WHODAS 2.0.) and for sexual problems (PRSexDQ-SALSEX).

Results

We found significant differences in the socio-demographic and the opioid-related variables as the onset of opioid use, being on previous maintenance programs, opioid intravenous use, the length of previous maintenance programs, polydrug use and elevated seroprevalence rates (HCV and HIV) between the methadone group and the buprenorphine group. Regarding health and disability domains there were differences in the Understanding and communication domain, Getting around domain, Participation in society domain and in the WHODAS 2.0. simple and complex score, favoring buprenorphine-treated patients. The methadone group referred elevated sexual impairments compared with the buprenorphine group. Opioid-related variables as seroprevalence rates, other previous lifetime maintenance program, the daily opioid dosage and the daily alcohol use are the most discriminative variables between both groups. Participation in society variables and sexual problems were the most important clinical variables in distinguishing the methadone group from the buprenorphine group regarding their functional status.

Conclusions

The methadone group showed higher prevalence in opioid dependence-related variables, elevated disabilities in participation in society activities and sexual problems compared with the buprenorphine group. This study shows the importance of carry out a functional evaluation in the healthcare follow-up, especially in those areas related with social activity and with sexual problems.

Network analysis of psychotic manifestations among cocaine users

Psychotic experiences can be described along a continuum ranging from no psychotic experience at all, to clinical psychotic disorder. Any individual in the general population may encounter psychotic experiences under certain circumstances. Transient Cocaine Induced Psychotic Symptoms (TCIPS) are a well described model of such circumstances. Therefore, our aim was to use a network analysis to get a better knowledge on the architecture of previously described risk factors and how they contributed to two different measures of psychosis (psychosis proneness and transient cocaine induced psychotic symptoms) This study is a secondary analysis conducted among 180 cocaine users in addiction care centers in Paris and Paris suburb, who were evaluated with the PDI (Peters Delusion Inventory) and the SAPS-CIP (Scale for the Assessment of Psychotic Symptoms - Cocaine Induced Psychosis). Schizophrenia diagnosis was extracted from medical record. Relevant variables significantly associated with SAPS-CIP total score or PDI at the first step were included in a network analysis to better figurate their respective associations. The network centrality measures showed that the product preferentially used (crack vs cocaine) was related to TCIPS, psychosis proneness and, to a lesser extent, schizophrenia. Secondly, in this model TCIPS is a mediator between intensive cocaine use and psychosis proneness. Thirdly, this study refines the previous knowledge on heavy cannabis use being a risk factor for TCIPS. The observed link is not direct but mediated by psychosis proneness.

Leveraging Nurses to Improve Care for Patients with Concurrent Disorders in Inpatient Mental Health Settings: A Scoping Review

Objective: Several challenges have been identified for patients with concurrent disorders and the providers that care for them, contributing to a pressing need for interventions to improve outcomes, particularly within inpatient mental health settings. Methods: A systematic search of peer-reviewed literature was conducted using four online databases: CINAHL, MEDLINE (Ovid), PsycInfo and Web of Science. Articles were selected based on inclusion criteria and additional articles were identified through hand searches. Study details were charted and qualitative synthesis was conducted. Results: Thirty two articles met inclusion criteria. A substantial focus within the literature was education, with higher levels of education shown to improve healthcare provider attitudes and practices. Within this overarching focus, four themes were identified: 1) education as an intervention to improve attitudes and increase confidence and knowledge; 2) strategies to support practice change, including interventions aimed at clinical leaders and methods to address substance use among inpatients; 3) frameworks to guide care; and 4) opportunities to expand nursing scope of practice. Conclusions: Given the substantial evidence indicating that education improves nurses' knowledge, attitudes and practices, there is great promise in expanding educational intervention opportunities for nurses to improve care and outcomes for patients with concurrent disorders-a priority patient population.

Impulsivity and Impulsivity-Related Endophenotypes in Suicidal Patients with Substance Use Disorders: an Exploratory Study

Suicidal behavior (SB) is a major problem in patients with substance use disorders (SUDs). However, little is known about specific SB risk factors in this population, and pathogenetic hypotheses are difficult to disentangle. This study investigated some SB and SUD-related endophenotypes, such as impulsivity, aggression, trait anger, and risk-taking behaviors (RTBs), in forty-eight patients with SUDs in relation to lifetime history of suicide attempts (SAs). Disorders related to alcohol, cannabis, cocaine, opiates, and hallucinogenic drugs were included. Lifetime SAs was significantly associated with both higher impulsivity and higher aggression, but not with trait anger. A higher number of RTBs were associated with lifetime SAs and higher impulsivity, but not with aggression and trait anger. Assessing these endophenotypes could refine clinical SB risk evaluation in SUDs patients by detecting higher-risk subgroups. An important limitation of this study is exiguity of its sample size. Its primary contribution is inclusion of all SUD types.

Interaction effects in the association between methadone maintenance therapy and experiences of racial discrimination in U.S. healthcare settings

BACKGROUND

Disparities in methadone maintenance therapy (MMT) outcomes have received limited attention, but there are important negative outcomes associated with MMT that warrant investigation. Racial discrimination is common in healthcare settings and affects opioid use disorder (OUD) treatment and comorbidities. However, race/ethnicity alone may not fully explain experiences of discrimination. MMT remains highly stigmatized and may compound the effect of race/ethnicity on discrimination in healthcare settings. We sought to quantify differential associations between MMT and experiences of racial discrimination between racial/ethnic groups in a U.S. national sample.

METHODS

We used the National Epidemiologic Survey on Alcohol and Related Conditions-III (2012-2013) to identify a subset of individuals with a lifetime OUD who had ever used MMT (survey n = 766; weighted population n = 5,276,507). We used multivariable logistic regression to model past-year experience of racial discrimination in a healthcare setting. We included an interaction term between race/ethnicity and MMT status to identify the odds of discrimination (MMT vs. no MMT [referent]) within racial/ethnic groups. We used survey procedures with weights to account for the parent study's complex survey design.

FINDINGS

Twenty-two percent of our sample experienced racial discrimination in a healthcare setting in the past year. Discrimination was more common among those who had ever used MMT (x2 = 10.00, p = 0.001) and racial/ethnic minorities (x2 = 23.15, p<0.001). The interaction effect was much stronger than the main effects of race/ethnicity and MMT status. MMT status (versus no MMT) was positively associated with discrimination among Blacks (aOR = 3.93, 95% CI = 3.87-3.98, p<0.001), Whites (aOR = 2.25, 95% CI = 2.23-2.27, p<0.001), and Latino/Latinas (aOR = 1.59, 95% CI = 1.55-1.62, p<0.001). Among American Indian/Alaska Natives (AI/AN), those who had used MMT had over thirty times the odds of racial discrimination, compared to their non-MMT counterparts (aOR = 32.78, 95% CI = 31.16-34.48, p<0.001).

CONCLUSION

Race/ethnicity alone did not sufficiently account for racial discrimination in healthcare settings among those with a lifetime OUD. MMT status was strongly associated with racial discrimination among AI/AN. Our strong interaction effect is indicative of an additional barrier to health services utilization among AI/AN, which has important implications for OUD treatment outcomes and comorbidities. Health promotion programs aimed at increased adoption of MMT are promising, but should be considered in the context of racial/ethnic disparities, drug use and MMT stigma, and implicit biases in clinical settings.

Opioid-related deaths in Europe: Strategies for a comprehensive approach to address a major public health concern

Use of illicit opioids and misuse of prescription opioids are the main causes of drug-related deaths across the world, and the continuing rise in opioid-related mortality, especially affecting North America, Australia and Europe, is a public health challenge. Strategies that may help to decrease the high levels of opioid-related mortality and morbidity and improve care across Europe include risk assessment and interventions to improve the use of opioid analgesics, e.g. prescription drug-monitoring programmes, education on pain management to reduce opioid prescribing, and the implementation of evidence-based primary prevention programmes to reduce the demand for opioids. For patients who develop opioid use disorder (a chronic and relapsing problematic use of opioids that causes clinical impairment or distress), treatment combining opiate receptor full or partial agonist medications for opioid-use disorder (MOUD) with psychosocial interventions is essential. However, in Europe a substantial proportion of the 1.3 million high-risk opioid users (defined as injecting drug use or regular use of opioids, mainly heroin) remain outside of dedicated treatment programmes. More widespread and easier access to MOUD could reduce mortality levels; via approaches such as primary care-led treatment models, and efforts to improve patient retention and adherence to treatment programmes. Other harm-reduction strategies, such as the use of MOUD at optimal doses, the provision of take-home naloxone, the introduction of supervised drug-consumption facilities, and patient education to reduce the risk of overdose may also be beneficial.

Comorbidity Patterns Among Patients With Opioid Use Disorder and Problem Gambling: ADHD Status Predicts Class Membership

Objective: Psychiatric comorbidities are highly prevalent among individuals affected by substance use disorders and those with non-substance-related addictive disorders such as gambling disorder. More recently, the frequent co-occurrence of substance use disorders and attention-deficit hyperactivity disorder (ADHD) has received particular attention. The aim of our study was to identify patterns of psychiatric comorbidity and to examine associations between patient group and ADHD status with class membership. Methods: Participants were patients with opioid use disorder enrolled in opioid maintenance treatment (OMT), either recruited from the community (n = 142; M age = 35.8 years; 38.7% female) or prison (n = 133; M age = 35.7 years; 21.8% female), and patients undergoing treatment for problem gambling (PrG; n = 80; M age = 43.1 years; 20% female). To enable direct comparisons, the following instruments were applied: Mini International Neuropsychiatric Interview, Adult ADHD self-report scale, Wender Utah Rating Scale, and European Addiction Severity Index. We used a latent class analysis (LCA) to identify psychiatric comorbidity patterns and a multinomial logistic regression to examine associations between patient group, ADHD status, age, and gender with class membership. Results: The LCA resulted in a three-class solution: (1) a class of individuals with a relatively low probability of current psychiatric comorbidities, except for a high probability of substance use disorders; (2) a class with markedly increased probabilities of current and recurrent psychiatric comorbidities, especially for major depression; and (3) a class with very low probabilities of psychiatric comorbidities, except for moderate probabilities of substance use disorders and antisocial personality disorder. Both OMT patients recruited from the community and those in prison were less likely than PrG patients to be assigned to the most burdened class with respect to psychiatric comorbidity (class 2). Further, both individuals with ADHD in childhood and those with adult ADHD were more likely members of class 2. Conclusions: PrG patients seem to be at an even higher risk for psychiatric comorbidities compared to OMT patients. Raising awareness among practitioners for the high prevalence of psychiatric comorbidities among patients with gambling disorder and individuals with ADHD is crucial to initiate adequate treatment and to improve response.

Study of sociodemographic correlates, anxiety, and depression among opioid dependents admitted in treatment centres in Sikkim, India

BACKGROUND

People with opioid use disorder have significant anxiety and depression which can be because of neuroplastic changes due to use of opioid or because of use as a self-medication to relieve depression and anxiety. During the last one decade, opioid use has reached an alarming proportion in Sikkim, India; but, any research related to anxiety and depression among opioid users has not been done.

AIMS

To assess for depression and anxiety disorders among the opioid dependence syndrome (ODS) participants and its severity, and to find the association with the sociodemographic characteristics.

METHOD

One hundred participants from three different drug detoxification and rehabilitation centres who were diagnosed with ODS as per the ICD-10, Diagnostic Criteria for Research were assessed cross-sectionally with the Addiction Severity Index to find out the substances abused and psychiatric morbidity. Anxiety, depression, and mania were graded with the Hamilton rating scales for anxiety and depression, and the Young Mania Rating Scale.

RESULTS

Mean age of participants was 29.6 (±6.24) years. Ninety six per cent were males. Most of the participants were using multiple opioid preparations. Thirty four per cent were using dextropropoxyphene containing pain killer followed by six per cent using codeine containing cough syrup. Eighty two per cent had depression; however, only 13% were found to have severe depression. Fifty six per cent had anxiety and six per cent were found to have mania. Most of the participants with ODS were single, attended at least secondary education, from urban locality, and were from high socioeconomic status.

CONCLUSION

anxiety and depression are highly prevalent among ODS people. Treatment should not be limited to management of ODS but also the comorbid psychiatric illness.

Rapid transition from methadone to buprenorphine using naltrexone-induced withdrawal: A case report

Background: Patients taking methadone for opioid use disorder may desire transition to buprenorphine for a number of reasons. However, the current recommended approach for this transition generally takes weeks to months as an outpatient, causing considerable discomfort to the patient and a heightened risk of relapse during the transition period. Case: We describe the case of a patient on methadone maintenance who was rapidly transitioned to buprenorphine because of her desire to not return to her methadone clinic. In order to rapidly transition the patient from methadone to buprenorphine, naltrexone was administered to precipitate acute opioid withdrawal, which was followed soon after by buprenorphine induction. Discussion: Rapid transition from methadone maintenance to buprenorphine can be accomplished in inpatients by precipitating acute withdrawal with naltrexone, providing an effective alternative for patients who cannot tolerate the typical protracted methadone taper required prior to buprenorphine induction as an outpatient.

Substance misuse in patients who have comorbid chronic pain in a clinical population receiving methadone maintenance therapy for the treatment of opioid dependence

AIMS

To compare specific substance misuse in treatment-seeking, opioid-dependent patients with and without comorbid chronic pain, and to assess the respective value of urinalysis and patient reports in assessing substance misuse.

METHODS

Participants comprised a clinical population in a regional NHS Substance Misuse Service in the East of Scotland (N = 521). The Brief Pain Inventory - Short Form was used to assess pain, and the Maudsley Addiction Profile and urinalysis were used to assess substance misuse at study inception. Urinalysis was used to assess substance misuse during the 5-year follow-up period. Data were hosted, linked, anonymized and analyzed within a national Safe Haven.

RESULTS

Compared with opioid-dependent patients with no pain, a significantly higher proportion of treatment-seeking, opioid-dependent patients with chronic pain were engaged in non-medical benzodiazepine use (69% versus 58%; p = 0.016) and illicit cannabinoid use (84% versus 65%; p = 0.025) at study inception. Furthermore, a significantly higher proportion of this group was shown to continue non-medical benzodiazepine use (70% versus 42%; p = 0.037) and illicit cannabinoid use (100% versus 31%; p = 0.002) during the 5-year follow-up period. There were significant correlations between drug screen results and patient-reported use of opioids (Tetrachoric ϱ = 0.4944; p < 0.001), benzodiazepines (Tetrachoric ϱ = 0.2641; p = 0.001) and cannabinoids (Tetrachoric ϱ = 0.8384; p < 0.001).

CONCLUSIONS

Whilst gaining control of illicit opioid use during treatment, opioid-dependent patients with comorbid chronic pain demonstrated persistent problematic use of benzodiazepines and cannabinoids. This pattern of misuse was shown to persist during the 5-year follow-up period.

Gender-specific study of recurrent suicide attempts in outpatients with multiple substance use disorders

BACKGROUND

people suffering from substance use disorders (SUD) often die by suicide, so that the prevention of suicide attempts (SA) remains a top priority in this population. SA recurrence is common and is associated with suicide death, but this phenotype has been overlooked in SUD populations. Thus, we aimed at identifying the risk factors of SA recurrence in SUD, controlling for both gender and levels of exposure to addictive substances, including tobacco.

METHODS

we consecutively recruited 433 treatment-seeking outpatients with either opiate or cocaine use disorder and assessed their lifetime history of addictive and suicidal symptoms by standardized questionnaires. They were reliably classified as never, single or recurrent (≥ 2) suicide attempters, whose characteristics were identified by multinomial regression, stratified by gender; and compared to our previous work on serious SA in order to identify common or different risk profiles.

RESULTS

86/140 (61%) suicide attempters reported recurrence. The mean number of SA was 3.1. Recurrence was independently associated with psychiatric hospitalization in both genders, with nicotine dependence in men and with sedative use disorders in women.

LIMITATIONS

psychiatric diagnoses were derived from the current medication regimen.

CONCLUSION

specific and possibly avoidable/treatable risk factors for the recurrence of SA in SUD have been identified for the first time, opening new avenues for research and prevention in this high-risk population. Apart from nicotine dependence, these risk factors were very similar to those of serious SA. Although this comparison is indirect for now, it suggests a common liability towards suicidal behavior.

The Cholinergic System as a Treatment Target for Opioid Use Disorder

Opioid overdoses recently became the leading cause of accidental death in the US, marking an increase in the severity of the opioid use disorder (OUD) epidemic that is impacting global health. Current treatment protocols for OUD are limited to opioid medications, including methadone, buprenorphine, and naltrexone. While these medications are effective in many cases, new treatments are required to more effectively address the rising societal and interpersonal costs associated with OUD. In this article, we review the opioid and cholinergic systems, and examine the potential of acetylcholine (ACh) as a treatment target for OUD. The cholinergic system includes enzymes that synthesize and degrade ACh and receptors that mediate the effects of ACh. ACh is involved in many central nervous system functions that are critical to the development and maintenance of OUD, such as reward and cognition. Medications that target the cholinergic system have been approved for the treatment of Alzheimer's disease, tobacco use disorder, and nausea. Clinical and preclinical studies suggest that medications such as cholinesterase inhibitors and scopolamine, which target components of the cholinergic system, show promise for the treatment of OUD and further investigations are warranted.

Which Psychopathological Syndromes Could Be Associated with the Risk of Suicide among Substance Users?

Background: Research has shown that suicide is a highly present phenomenon among the drug dependent population. Moreover, individuals with substance use disorder (SUD) present high psychopathological comorbidity. This study aimed to describe which clinical syndromes are linked to the presence of risk of suicide. Methods: The study was based on a consecutive non-probabilistic convenience sample of 196 patients who attended the Public Addiction Center in Girona (Spain). Sociodemographic data, as well as suicide risk and drug related characteristics, were recorded. The risk of suicide was assessed with the Spanish version of "risk of suicide". Complicated grief was assessed with the Spanish version of the Inventory of Complicated Grief. Clinical syndromes were measured with the Spanish version of MCMI-III. Results: The syndromes most frequently associated with the presence of risk of suicide were complicated grief, major depression and thought disorder. Conclusions: Different psychopathological syndromes were identified in relation to risk of suicide among patients with SUD. The present results highlight the importance of accurately diagnosing those individuals.

Improving outcomes in the treatment of opioid dependence (IOTOD): reflections on the impact of a medical education initiative on healthcare professionals' attitudes and clinical practice

Since 2011, the annual improving outcomes in the treatment of opioid dependence (IOTOD) meeting has brought together a broad range of primarily European healthcare professionals as part of an ongoing effort to promote best practice for this particularly vulnerable patient population. IOTOD, a comprehensive educational initiative, includes the annual Continuing Medical Education (CME)-accredited IOTOD conference, which is dedicated to measuring practice change and outcomes resulting from attendance at its educational sessions. Following each session, delegates are asked to vote for or against incorporating specified changes into their clinical practice. These "commitments to change" have formed one measure of the effectiveness and impact of the IOTOD conference. Here, we look at why educational initiatives like the IOTOD conference are valuable, examine our methods for conducting a CME-accredited event, and highlight individualised treatment plans and delivery. We examine this approach - increasingly seen as best practice - as an example of how it may be changing attitudes and eventually affecting clinical applications in the field of opioid dependence. The measured commitments to change offer insight into HCPs' attitudes towards opioid dependence management and show that attitudes towards individualised treatment plans seem to be progressively positive, with a general consensus to incorporate psychosocial interventions.

Direct-acting antiviral treatment of chronic HCV-infected patients on opioid substitution therapy: Still a concern in clinical practice?

BACKGROUND AND AIMS

There is limited real-world information on the effectiveness of antiviral treatment of chronic hepatitis C virus (HCV) infection with direct-acting antivirals (DAA) in people on opioid substitution therapy (OST). This study compared sustained virological response (SVR) rates and proportion of lost to follow-up (LTFU) between OST and non-OST patients in the German Hepatitis C-Registry (DHC-R).

DESIGN

National multi-centre prospective real-world registry (German Hepatitis C-Registry, DHC-R). Non-OST patients comprised patients with former/current drug use (non-OST/DU) and patients never consuming drugs (non-OST/NDU).

SETTING

A total of 254 medical centres in Germany, including 123 centres providing OST.

PARTICIPANTS

A total of 7747 chronic HCV patients started DAA therapy (739 OST and 7008 non-OST; 1500 non-OST/DU; 5508 non-OST/NDU) patients. Five hundred and twenty-eight OST and 5582 non-OST patients had completed antiviral therapy and at least one follow-up documentation [intention-to-treat (ITT) population].

MEASUREMENTS

Study outcomes were SVR, proportion of LTFU and safety of treatment.

FINDINGS

SVR (ITT) was documented in 85% (450 of 528) OST patients versus 86% (969 of 1126) in non-OST/DU (P = 0.651) and 92% (4113 of 4456) non-OST/NDU (P < 0.001) patients. Independent predictors for SVR (P < 0.01 in multivariate analysis) included HCV genotype non-3 [adjusted odds ratio (aOR) = 1.11; 95% confidence interval (CI) = 1.07-1.15], female sex (aOR = 1.59; CI = 1.30-1.94), platelet counts >90 × 109/l (aOR = 1.51, CI = 1.14-2.01), cirrhosis (aOR = 0.77; CI = 0.62-0.96) and patient group (OST/DI (aOR = 0.58; CI = 0.42-0.78); non-OST/DU (OR: 0.63; CI = 0.50-0.78). In per-protocol analysis (PP), SVR rates were ≥ 94% in all patient groups. In OST the proportion of LTFU was higher (10.2%) than in non-OST/DU (8.5%) and non-OST/NDU (3.2%, P < 0.001) patients. Independent factors for LTFU (P < 0.01) were HCV genotype non-3 (aOR = 0.92; CI = 0.88-0.96), female sex (aOR: 0.7; CI = 0.53-0.92), pre-treatment (aOR = 0.64; CI = 0.50-0.82), OST/DI (aOR = 3.35; CI = 2.35-4.78) and non-OST/DU (aOR = 2.38; CI = 1.80-3.14).

CONCLUSIONS

In Germany, direct-acting antiviral treatment of former or current drug users with or without opioid substitution therapy can achieve equally high sustained virological response rates as in patients with no history of drug use.

Factors associated with lifetime suicidal ideation and suicide attempts in outpatients with substance use disorders

Risks factors for suicide are multiple and highly prevalent in addicted patients (previous suicide attempts, substance abuse, impulsivity, history of sexual abuse and other factors). The aim of this study is to identify and to compare the clinical and socio-demographic profile of SUD outpatients with lifetime suicidal behavior (previous suicidal ideation and/or suicide attempts) and to analyze the factors related to it. A retrospective cohort study of 696 addicted patients, according to DSM-IV-TR criteria (APA, 2000) were collected from the Addiction Unit of Vall d'Hebron University Hospital. Lifetime suicidal ideation in addicted patients is associated with presence of: borderline personality disorder (BPD), depressive disorders, sexual abuse, polydrug abuse, attention-deficit hyperactivity disorder, and motor impulsivity. The factors associated with suicide attempts were: borderline personality disorder, lifetime abuse (whether emotional, physical or sexual), co-occurrent psychotic disorders, polydrug abuse, anxiety disorders and depressive symptoms. We conclude that previous suicidal ideation and lifetime suicide attempts should be considered in the clinical care of addicted patients. Factors related to both suicidal behaviors share similarities and differences according to our findings and need to be deeply explored in the future.

The long-term outcome of patients with heroin use disorder/dual disorder (chronic psychosis) after admission to enhanced methadone maintenance

BACKGROUND

Over-standard methadone doses are generally needed in the treatment of heroin use disorder (HUD) patients that display concomitant high-severity psychopathological symptomatology. A flexible dosing regimen may lead to higher retention rates in dual disorder (DD), as we demonstrated in bipolar 1 HUD patients, leading to outcomes that are as satisfactory as those of HUD patients without high-severity psychopathological symptomatology.

OBJECTIVE

This study aimed to compare the long-term outcomes of treatment-resistant chronic psychosis HUD patients (PSY-HUD) with those of peers without dual disorder (HUD).

METHODS

85 HUD patients who also met the criteria for treatment resistance-25 of them affected by chronic psychosis and 60 without DD-were monitored prospectively for up to 8 years while continuing to receive enhanced methadone maintenance treatment.

RESULTS

The rates of endurance in the treatment of PSY-HUD patients were 36%, compared with 34% for HUD patients (p = 0.872). After 3 years of treatment, these rates tended to become progressively more stable. PSY-HUD patients showed better outcome results than HUD patients regarding CGI severity (p < 0.001) and DSM-IV-GAF (p < 0.001). No differences were found regarding good toxicological outcomes or the methadone dosages used to achieve stabilization. The time required to stabilize PSY-HUD patients was shorter (p = 0.034).

CONCLUSIONS

An enhanced methadone maintenance treatment seems to be equally effective in patients with PSY-HUD and those with HUD.

Personality Profile and Clinical Correlates of Patients With Substance Use Disorder With and Without Comorbid Depression Under Treatment

Background: Among patients with substance use disorder (SUD), major depressive disorder (MDD) is highly prevalent. Even though, personality plays an important role in treatment outcomes for individuals with SUD and SUD + MDD, few studies have explored personality characteristics in these samples. This study aims to describe personality for patients with SUD taking into account the comorbid MDD, using the Alternative Five Factor Model (AFFM). We also aim to compare SUD + MDD patients with population norms and to elucidate possible personality clinical correlates. Methods: For our study, 116 male patients undergoing for SUD treatment were divided in two groups: SUD only (N = 58) and SUD + MDD (N = 58). To examine personality, we used the Zuckerman-Kuhlman Personality Questionnaire and multiple analyses of covariance were performed to identify differences. In a first analysis, age was introduced as a covariate whereas in a second analysis the continuous variables that showed to have a discriminant value for the groups were added as covariates. Variables predicting the presence of dual diagnosis and personality clinical correlates were analyzed by logistic and linear regression models, respectively. We observed that patients with SUD + MDD show distinctive personality characteristics compared with patients with SUD only and population norms. Results: According to the AFFM, SUD + MDD patients are characterized by higher Neuroticism-Anxiety (positively associated to depressive symptoms) and Impulsivity; and by lower Parties and Friends. Moreover, the probability of having a dual depressive disorder was represented by the amount of medications and substances used. The preference for hard work and the energy self-reported levels (Work Activity trait) are linked to these clinical variables rather than to the presence/absence of a dual depressive disorder. Conclusions: Even when controlling clinical variables related to a higher probability of having a dual depressive disorder, the Neuroticism-Anxiety is a personality trait that strongly differentiates between SUD only and SUD + MDD patients. Further investigation is needed to explore the role of this personality trait as endophenotype in dual depressive men. Our results underline the importance of a dimensional understanding of personality and its clinical correlates among patients with SUD + MDD; this approach could provide us information on specific treatment strategies to improve the prognosis of patients.

Serious suicide attempts in outpatients with multiple substance use disorders

BACKGROUND

Suicide is a major public health concern and suicide attempts (SA) are frequent and burdensome in people suffering from substance use disorders (SUDs). In particular, serious SAs are a preoccupying form of attempt, which remain largely overlooked in these populations, especially regarding basic risk factors such as gender, addictive comorbidity and substance use patterns. Thus, we undertook a gender-specific approach to identify the risk factors for serious SAs in outpatients with multiple SUDs.

MATERIAL AND METHODS

433 Treatment-seeking outpatients were consecutively recruited in specialized care centers and reliably classified as serious, non-serious and non-suicide attempters. We also characterized lifetime exposure to SUDs, including tobacco smoking, with standardized instruments. Current medication, including psychotropic treatments were collected, which informed psychiatric diagnoses. Multinomial regression identified independent factors specifically associated with serious SAs in each gender, separately.

RESULTS

32% Participants (N=139, 47% Women and 27% Men) reported lifetime SA. There were 82 serious attempters (59% of attempters), without significant gender difference. Sedative dependence was an independent risk factor for serious SA compared to non-SA in Women and compared to non-serious SA in Men, respectively. Other risk factors included later onset of daily tobacco smoking in Men and history of psychiatric hospitalizations in Women, whose serious SA risk was conversely lower when reporting opiate use disorder or mood disorder, probably because of treatment issues.

CONCLUSIONS

Despite several study limitations, we identified subgroups for a better-tailored prevention of serious SAs among individuals with SUDs, notably highlighting the need to better prevent and treat sedative dependence.

The role of dual diagnosis in health-related quality of life among treatment-seeking patients in Spain

PURPOSE

The comorbidity of any substance use disorder and another mental disorder is defined as dual diagnosis. Dual diagnosis is very common and clinical and therapeutic consequences have been described. This cross-sectional study aimed to analyse health-related quality of life (HRQoL) according to clinical characteristics and psychiatric comorbidities in patients with substance dependence.

METHODS

A total of 1276 substance-dependent patients seeking treatment were recruited. HRQoL was evaluated by the Short-Form 36 (SF-36) questionnaire. The SCID-I, SCID-II and Conners' adult ADHD diagnostic interview were used to evaluate dual diagnosis. A visual analogue scale was used to measure craving. Bivariate and multivariate analyses were performed, and correction for multiple tests was conducted.

RESULTS

Substance-dependent patients had impaired quality of life, especially in the mental component. SF-36 physical and mental component scores were 47.7 ± 10.9 and 36.1 ± 14.1, respectively. Furthermore, 65% of the patients had dual diagnosis, 51% had an Axis I DSM-IV-TR mental disorder and 35% had some personality disorder. Impaired physical quality of life was independently associated with medical condition, age, being female, depressive disorder and anxiety disorder. Depression disorder, any personality disorder, active consumption last month, Attention deficit hyperactivity disorder, anxiety disorder, suicide attempt were independently associated with worse mental quality of life.

CONCLUSION

These findings emphasize the significance of dual diagnosis in the impairment of HRQoL in substance-dependent patients, particularly with regard to mental component. In addicted patients with low scores on SF-36, psychiatric comorbidity should be evaluated and treated in an integrated approach.

Differences between craving and health-related quality of life in patients with alcohol dependence with or without dual pathology in outpatient treatment: A descriptive study

BACKGROUND AND OBJECTIVE

Dual diagnosis is the coexistence of an addictive disorder and another mental disorder. The objective is to estimate cravings and self-reported quality of life in a sample of patients with alcoholic dependence, with or without dual pathology, who attend an outpatient treatment centre.

PATIENTS AND METHOD

A cross-sectional study of 112 patients (56 dual and 56 non-dual), diagnosed with alcohol dependence according to DSM-IV-TR. The presence of cravings is determined by the Multidimensional Alcohol Craving Scale and quality of life through the SF-36 Health Questionnaire.

RESULTS

There are no statistically significant differences in cravings in either subgroup; the latter tend to refer to lower alcohol cravings than non-dual patients. The dual patients have a worse quality of life in all categories evaluated, highlighting a worse quality of life in the categories: social function, emotional role, vitality and general health. Females present a lower quality of life emphasising those of social function and emotional role. No differences were detected in relation to cravings between the 2 groups.

CONCLUSIONS

In order to perform a correct clinical and therapeutic approach for patients with alcohol dependence, we should consider focusing on the evaluation of cravings and quality of life. In order to perform a correct clinical and therapeutic approach for patients with alcohol dependence, it is necessary to consider cravings and quality of life, since these parameters are important for the evaluation of patients with alcohol dependence.