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Brandt L, Odom GJ, Hu MC, Castro C, Balise RR. Empirically contrasting urine drug screening-based opioid use disorder treatment outcome definitions. Addiction 2024; 119:1289-1300. [PMID: 38616571 DOI: 10.1111/add.16494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 02/21/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND AND AIMS A lack of consensus on the optimal outcome measures to assess opioid use disorder (OUD) treatment efficacy and their precise definition and computation has hampered the pooling of research data for evidence synthesis and meta-analyses. This study aimed to empirically contrast multiple clinical trial definitions of treatment success by applying them to the same dataset. METHODS Data analysis used a suite of functions, developed as a software package for the R language, to operationalize 61 treatment outcome definitions based on urine drug screening (UDS) results. Outcome definitions were derived from clinical trials that are among the most influential in the OUD treatment field. Outcome functions were applied to a harmonized dataset from three large-scale National Drug Abuse Treatment Clinical Trials Network (CTN) studies, which tested various medication for OUD (MOUD) options (n = 2492). Hierarchical clustering was employed to empirically contrast outcome definitions. RESULTS The optimal number of clusters identified was three. Cluster 1, comprising eight definitions focused on detecting opioid-positive UDS, did not include missing UDS in outcome calculations, potentially resulting in inflated rates of treatment success. Cluster 2, with the highest variability, included 10 definitions characterized by strict criteria for treatment success, relying heavily on UDS results from either a brief period or a single study visit. The 43 definitions in Cluster 3 represented a diverse range of outcomes, conceptualized as measuring abstinence, use reduction and relapse. These definitions potentially offer more balanced measures of treatment success or failure, as they avoid the extreme methodologies characteristic of Clusters 1 and 2. CONCLUSIONS Clinical trials using urine drug screening (UDS) for objective substance use assessment in outcome definitions should consider (1) incorporating missing UDS data in outcome computation and (2) avoiding over-reliance on UDS data confined to a short time frame or the occurrence of a single positive urine test following a period of abstinence.
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Affiliation(s)
- Laura Brandt
- Department of Psychology, The City College of New York, New York, New York, USA
| | - Gabriel J Odom
- Department of Biostatistics, Florida International University, Miami, Florida, USA
| | - Mei-Chen Hu
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
| | - Clinton Castro
- The Information School, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Raymond R Balise
- Division of Biostatistics, Department of Public Health Sciences, The University of Miami, Miami, Florida, USA
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Odom GJ, Brandt L, Castro C, Luo SX, Feaster DJ, Balise RR. Capturing drug use patterns at a glance: An n-ary word sufficient statistic for repeated univariate categorical values. PLoS One 2023; 18:e0291248. [PMID: 37682922 PMCID: PMC10490938 DOI: 10.1371/journal.pone.0291248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 08/24/2023] [Indexed: 09/10/2023] Open
Abstract
INTRODUCTION The efficacy of treatments for substance use disorders (SUD) is tested in clinical trials in which participants typically provide urine samples to detect whether the person has used certain substances via urine drug screenings (UDS). UDS data form the foundation of treatment outcome assessment in the vast majority of SUD clinical trials. However, existing methods to calculate treatment outcomes are not standardized, impeding comparability between studies and prohibiting reproducibility of results. METHODS We extended the concept of a binary UDS variable to multiple categories: "+" [positive for substance(s) of interest], "-" [negative for substance(s)], "o" [patient failed to provide sample], "*" [inconclusive or mixed results], and "_" [no specimens required per study design]. This construct can be used to create a standardized and sufficient representation of UDS datastreams and sufficiently collapses longitudinal records into a single, compact "word", which preserves all information contained in the original data. RESULTS We developed the R software package CTNote (available on CRAN) as a tool to enable computers to parse these "words". The software package contains five groups of routines: detect a substance use pattern, account for a specific trial protocol, handle missing UDS data, measure the longest period of consecutive behavior, and count substance use events. Executing permutations of these routines result in algorithms which can define SUD clinical trial endpoints. As examples, we provide three algorithms to define primary endpoints from seminal SUD clinical trials. DISCUSSION Representing substance use patterns as a "word" allows researchers and clinicians an "at a glance" assessment of participants' responses to treatment over time. Further, machine readable use pattern summaries are a standardized method to calculate treatment outcomes and are therefore useful to all future SUD clinical trials. We discuss some caveats when applying this data summarization technique in practice and areas of future study.
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Affiliation(s)
- Gabriel J. Odom
- Department of Biostatistics, Florida International University, Miami, FL, United States of America
| | - Laura Brandt
- Department of Psychology, The City College of New York, New York City, NY, United States of America
| | - Clinton Castro
- The Information School, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Sean X. Luo
- Department of Psychiatry, Columbia University, New York City, NY, United States of America
| | - Daniel J. Feaster
- Division of Biostatistics, Department of Public Health Sciences, The University of Miami, Miami, FL, United States of America
| | - Raymond R. Balise
- Division of Biostatistics, Department of Public Health Sciences, The University of Miami, Miami, FL, United States of America
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Lier AJ, Vander Wyk B, Di Paola A, Springer SA. Evaluation of the Impact of HIV Serostatus on the Hepatitis C Virus Care Cascade and Injection Drug Use Among Persons Initiating Medication Treatment for Opioid Use Disorder. Open Forum Infect Dis 2022; 9:ofac624. [PMID: 36467300 PMCID: PMC9709708 DOI: 10.1093/ofid/ofac624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 11/11/2022] [Indexed: 11/16/2022] Open
Abstract
Background Persons who inject drugs are at increased risk for acquiring hepatitis C virus (HCV). Medications for opioid use disorder (MOUD) are associated with reduced injection drug use (IDU) frequency among persons with opioid use disorder (OUD). However, whether HCV treatment uptake or changes in IDU frequency differ by HIV serostatus among persons receiving MOUD is incompletely understood. Methods A secondary analysis was performed of data collected from 2 prospective cohort studies of participants with (PWH) or without HIV with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition-diagnosed OUD who were initiated on methadone, buprenorphine, or naltrexone. Results Of 129 participants, 78 (60.5%) were HCV antibody positive. PWH underwent increased HCV viral load testing (76.7% vs 43.3%; P = .028), but HCV treatment rates did not differ (17.6% vs 10.0%; P = .45) by HIV status. Participants without HIV reported a greater reduction in mean opioid IDU at 90 days (10.7 vs 2.0 fewer days out of 30; P < .001), but there were no group differences at 90 days. Stimulant use did not differ between groups. Urine opioid positivity declined from baseline to 90 days among the entire cohort (61.4% to 38.0%; P < .001) but did not differ by HIV serostatus. Conclusions PWH who received MOUD underwent higher rates of follow-up HCV testing, but HCV treatment rates did not significantly differ by HIV serostatus. Participants without HIV on MOUD reported a greater reduction in opioid IDU. Improved integration of concomitant OUD with HCV and HIV screening, linkage to care, and treatment are needed for persons without HIV.
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Affiliation(s)
- Audun J Lier
- Division of Infectious Diseases, Department of Medicine, Northport VA Medical Center, Northport, New York, USA
| | - Brent Vander Wyk
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Angela Di Paola
- AIDS Program, Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sandra A Springer
- AIDS Program, Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Lier AJ, Seval N, Vander Wyk B, Di Paola A, Springer SA. Maintenance on extended-release naltrexone is associated with reduced injection opioid use among justice-involved persons with opioid use disorder. J Subst Abuse Treat 2022; 142:108852. [PMID: 35988513 PMCID: PMC9509444 DOI: 10.1016/j.jsat.2022.108852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/05/2022] [Accepted: 07/26/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Opioid use disorder (OUD) and injection drug use (IDU) place justice-involved individuals at increased risk for acquiring or transmitting HIV or hepatitis C virus (HCV). Methadone and buprenorphine have been associated with reduced opioid IDU; however, the effect of extended-release naltrexone (XR-NTX) on this behavior is incompletely studied. METHODS This study examined injection opioid use and shared injection equipment behavior from a completed double-blind placebo-controlled trial of XR-NTX among 88 justice-involved participants with HIV and OUD. Changes in participants' self-reported daily injection opioid use and shared injection equipment was evaluated pre-incarceration, during incarceration, and monthly post-release for 6 months. The study also assessed differences in time to first opioid injection post-release. The research team performed intention to treat and "as treated" (high treatment versus low treatment) analyses. RESULTS Fifty-eight of 88 participants (69.5 %) endorsed IDU and 26 (29.5 %) reported sharing injection equipment in the 30 days pre-incarceration; 2 participants (2.2 %) reported IDU during incarceration; 19 (21.6 %) reported IDU one month post-release from prison or jail. Fifty-four (61.4 %) participants had an HIV RNA below 200 copies/mL and 62 (70.5 %) were baseline HCV antibody positive. The 6-month follow-up rate was 49.5 % and 50.5 % for those who received XR-NTX and placebo, respectively, which was not significantly different (p = 0.822). Participants in the XR-NTX and placebo groups had similar low mean opioid injection use post-release and time to first injection opioid use in the Intention-to-treat analysis. In the as-treated analysis, participants in the high treatment group had significantly lower mean proportion of days injecting opioids (13.8 % high treatment versus 22.8 % low treatment, p = 0.02) by month 1, which persisted up to 5 months post-release (0 % high treatment vs 24.3 % low treatment, p < 0.001) and experienced a longer time to first opioid injection post-release (143.8 days high treatment vs 67.4 days low treatment, p < 0.001). CONCLUSIONS Injection opioid use was low during incarceration and remained low post-release in this justice-involved population. Retention on XR-NTX was associated with reduced intravenous opioid use, which has important implications for reducing transmission of HIV and HCV.
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Affiliation(s)
- Audun J Lier
- Department of Internal Medicine, Division of Infectious Diseases, Northport VA Medical Center, Northport, NY, USA
| | - Nikhil Seval
- Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, New Haven, CT, USA
| | - Brent Vander Wyk
- Department of Internal Medicine, Section of Geriatrics, Yale School of Medicine, New Haven, CT, USA
| | - Angela Di Paola
- Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, New Haven, CT, USA
| | - Sandra A Springer
- Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, New Haven, CT, USA; Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT, USA.
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Perry C, Liberto J, Milliken C, Burden J, Hagedorn H, Atkinson T, McKay JR, Mooney L, Sall J, Sasson C, Saxon A, Spevak C, Gordon AJ. The Management of Substance Use Disorders: Synopsis of the 2021 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline. Ann Intern Med 2022; 175:720-731. [PMID: 35313113 DOI: 10.7326/m21-4011] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
DESCRIPTION In August 2021, leadership within the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline (CPG) for the management of substance use disorders (SUDs). This synopsis summarizes key recommendations. METHODS In March 2020, the VA/DoD Evidence-Based Practice Work Group assembled a team to update the 2015 VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders that included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy CPGs. The guideline panel developed key questions, systematically searched and evaluated the literature, created two 1-page algorithms, and distilled 35 recommendations for care using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. This synopsis presents the recommendations that were believed to be the most clinically impactful. RECOMMENDATIONS The scope of the CPG is broad; however, this synopsis focuses on key recommendations for the management of alcohol use disorder, use of buprenorphine in opioid use disorder, contingency management, and use of technology and telehealth to manage patients remotely.
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Affiliation(s)
| | - Joseph Liberto
- Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, DC (J.L.)
| | - Charles Milliken
- Office of the Surgeon General, U.S. Army, Bethesda, Maryland (C.M.)
| | - Jennifer Burden
- Office of Mental Health and Suicide Prevention, Veterans Health Administration, Salem, Virginia (J.B.)
| | - Hildi Hagedorn
- Center for Care Delivery & Outcomes Research, Minneapolis VA Medical Center, Minneapolis, Minnesota (H.H.)
| | - Timothy Atkinson
- VA Tennessee Valley Healthcare System, Murfreesboro, Tennessee (T.A.)
| | - James R McKay
- Center of Excellence in Substance Addiction Treatment and Education, Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania (J.R.M.)
| | - Larissa Mooney
- VA Greater Los Angeles Healthcare System, Los Angeles, California (L.M.)
| | - James Sall
- Quality and Patient Safety, Veterans Administration Central Office, Washington, DC (J.S.)
| | - Comilla Sasson
- Medical Advisory Panel, VA Medical Center and Pharmacy Benefits Management, Denver, Colorado (C.S.)
| | - Andrew Saxon
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, Seattle, Washington (A.S.)
| | | | - Adam J Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences Center (IDEAS), VA Salt Lake City Healthcare System, and Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), University of Utah, Salt Lake City, Utah (A.J.G.)
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Lim J, Farhat I, Douros A, Panagiotoglou D. Relative effectiveness of medications for opioid-related disorders: A systematic review and network meta-analysis of randomized controlled trials. PLoS One 2022; 17:e0266142. [PMID: 35358261 PMCID: PMC8970369 DOI: 10.1371/journal.pone.0266142] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/15/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Several pharmacotherapeutic interventions are available for maintenance treatment for opioid-related disorders. However, previous meta-analyses have been limited to pairwise comparisons of these interventions, and their efficacy relative to all others remains unclear. Our objective was to unify findings from different healthcare practices and generate evidence to strengthen clinical treatment protocols for the most widely prescribed medications for opioid-use disorders. METHODS We searched Medline, EMBASE, PsycINFO, CENTRAL, and ClinicalTrials.gov for all relevant randomized controlled trials (RCT) from database inception to February 12, 2022. Primary outcome was treatment retention, and secondary outcome was opioid use measured by urinalysis. We calculated risk ratios (RR) and 95% credible interval (CrI) using Bayesian network meta-analysis (NMA) for available evidence. We assessed the credibility of the NMA using the Confidence in Network Meta-Analysis tool. RESULTS Seventy-nine RCTs met the inclusion criteria. Due to heterogeneity in measuring opioid use and reporting format between studies, we conducted NMA only for treatment retention. Methadone was the highest ranked intervention (Surface Under the Cumulative Ranking [SUCRA] = 0.901) in the network with control being the lowest (SUCRA = 0.000). Methadone was superior to buprenorphine for treatment retention (RR = 1.22; 95% CrI = 1.06-1.40) and buprenorphine superior to naltrexone (RR = 1.39; 95% CrI = 1.10-1.80). However, due to a limited number of high-quality trials, confidence in the network estimates of other treatment pairs involving naltrexone and slow-release oral morphine (SROM) remains low. CONCLUSION All treatments had higher retention than the non-pharmacotherapeutic control group. However, additional high-quality RCTs are needed to estimate more accurately the extent of efficacy of naltrexone and SROM relative to other medications. For pharmacotherapies with established efficacy profiles, assessment of their long-term comparative effectiveness may be warranted. TRIAL REGISTRATION This systematic review has been registered with PROSPERO (https://www.crd.york.ac.uk/prospero) (identifier CRD42021256212).
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Affiliation(s)
- Jihoon Lim
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
| | - Imen Farhat
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
| | - Antonios Douros
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
- Department of Medicine, McGill University, Montreal, QC, Canada
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada
- Institute of Clinical Pharmacology and Toxicology, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Dimitra Panagiotoglou
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
- * E-mail:
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Kays LB, Steltenpohl ED, McPheeters CM, Frederick EK, Bishop LB. Initiation of Buprenorphine/Naloxone on Rates of Discharge Against Medical Advice. Hosp Pharm 2022; 57:88-92. [PMID: 35521020 PMCID: PMC9065509 DOI: 10.1177/0018578720985439] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Objective: Evidence shows that patients with opioid use disorder (OUD) have an increased rate of discharge against medical advice (DAMA) as well as higher rates of hospital readmission. Therefore, the objective of this study was to determine if inpatient initiation of buprenorphine/naloxone in patients with OUD is associated with decreased rates of DAMA. Methods: This was a single center retrospective cohort study conducted at a level 1, academic medical center. The study included patients with OUD admitted to the Internal Medicine service from January through May of both 2018 and 2019 for an admitting diagnosis other than opioid withdrawal. The primary endpoint was rate of DAMA among OUD patients not initiated on opioid agonist therapy compared to those initiated on buprenorphine/naloxone. The secondary endpoint was the association between factors of the initiation process on rates of DAMA. Patients were excluded if they were discharged in less than 24 hours or received intermittent administration of buprenorphine/naloxone. Results: The rate of DAMA in OUD patients not initiated on buprenorphine/naloxone was 13.85% compared to 2.56% in those initiated on buprenorphine/naloxone (P = .048). Conclusion: In OUD patients initiated on buprenorphine/naloxone, the rate of DAMA was significantly lower than those who were not. This data supports the importance of optimizing the opportunity to initiate buprenorphine/naloxone in the acute care setting to minimize withdrawal symptoms therefore reducing the rate of DAMA. Ultimately increasing the ability to adequately treat the primary reason for admission and potentially decreasing readmission rates. Further studies are needed to evaluate this impact as this study is limited to a small sample size therefore lacking adequate power.
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Affiliation(s)
- Lindsey B. Kays
- University of Louisville Hospital, Louisville, KY, USA,Lindsey B. Kays, University of Louisville Hospital, 550 S. Jackson St., Louisville, KY 40202, USA.
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Zangiabadian M, Golmohammadi S, Nejadghaderi SA, Zahmatkesh MM, Nasiri MJ, Sadeghian M. The effects of naltrexone on retention in treatment and being opioid-free in opioid-dependent people: A systematic review and meta-analysis. Front Psychiatry 2022; 13:1003257. [PMID: 36226100 PMCID: PMC9548642 DOI: 10.3389/fpsyt.2022.1003257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/08/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Opioid dependency is a chronic relapsing disorder for which different therapeutically interventions have been developed. Naltrexone is a non-selective opioid antagonist that can be utilized for maintenance therapy in opioid dependency. In this systematic review, we aimed to evaluate the effects of naltrexone on retention in treatment and being opioid-free. METHODS We systematically searched PubMed and EMBASE databases up to February 5, 2022, using the following keywords: "Naltrexone," "Substance abuse," "Drug abuse," "Opiate-related disorder," and "Opioid dependence." Studies that included opiate-dependent individuals who were treated with naltrexone and assessed retention in treatment or being opioid-free were included. Two authors independently used the Cochrane risk-of-bias tool for quality assessment. A random effect model in Comprehensive Meta-Analysis software was used for the conduction of the meta-analysis. We performed subgroup analysis to evaluate the effects of naltrexone types on outcomes. RESULTS Eighteen studies, including 2,280 participants met our inclusion criteria. The duration of treatment ranged from 21 days to 24 months. The retention in treatment with naltrexone was 63% higher than controls (odds ratio (OR): 1.64 [95% confidence interval (CI), 0.78-3.44]. The OR for being opioid-free was 1.63 (95% CI, 0.57-4.72). Injectable naltrexone was significantly effective on retention in treatment (OR 1.86; 95% CI, 1.17-2.98). CONCLUSIONS We found that naltrexone could be useful for retention in treatment and being opioid-free, however, the findings were not significant. Further high-quality and large-scale observational studies are recommended.
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Affiliation(s)
- Moein Zangiabadian
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saeid Golmohammadi
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Aria Nejadghaderi
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Mahdi Zahmatkesh
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Javad Nasiri
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Majid Sadeghian
- Department of Psychiatry, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Stancil SL, Abdel-Rahman S, Wagner J. Developmental Considerations for the Use of Naltrexone in Children and Adolescents. J Pediatr Pharmacol Ther 2021; 26:675-695. [PMID: 34588931 DOI: 10.5863/1551-6776-26.7.675] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/27/2021] [Indexed: 11/11/2022]
Abstract
Naltrexone (NTX) is a well-tolerated drug with a wide safety margin and mechanism of action that affords use across a wide variety of indications in adults and children. By antagonizing the opioid reward system, NTX can modulate behaviors that involve compulsivity or impulsivity, such as substance use, obesity, and eating disorders. Evidence regarding the disposition and efficacy of NTX is mainly derived from adult studies of substance use disorders and considerable variability exists. Developmental changes, plausible disease-specific alterations and genetic polymorphisms in NTX disposition, and pharmacodynamic pathways should be taken into consideration when optimizing the use of NTX in the pediatric population. This review highlights the current state of the evidence and gaps in knowledge regarding NTX to facilitate evidence-based pharmacotherapy of mental health conditions, for which few pharmacologic options exist.
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Schottenfeld RS, Chawarski MC, Mazlan M. Behavioral counseling and abstinence-contingent take-home buprenorphine in general practitioners' offices in Malaysia: a randomized, open-label clinical trial. Addiction 2021; 116:2135-2149. [PMID: 33404150 DOI: 10.1111/add.15399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 05/27/2020] [Accepted: 12/23/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIM To address the widespread severe problems with opioid use disorder, buprenorphine-naloxone treatment provided by primary care physicians has greatly expanded treatment access; however, treatment is often provided with minimal or no behavioral interventions. Whether or which behavioral interventions are feasible to implement in various settings and improve treatment outcomes has not been established. This study aimed to evaluate two behavioral interventions to improve buprenorphine-naloxone treatment. DESIGN A 2 × 2 factorial, repeated-measures, open-label, randomized clinical trial. SETTINGS General medical practice offices in Muar, Malaysia. PARTICIPANTS Opioid-dependent individuals (n = 234). INTERVENTIONS Participants were randomly assigned to one of four treatment conditions and received study interventions for 24 weeks: (1) physician management with or without behavioral counseling and (2) physician management with or without abstinence-contingent buprenorphine-naloxone (ACB) take-home doses. MEASUREMENTS The primary outcomes were proportions of opioid-negative urine tests and HIV risk behaviors [assessed by audio computer-assisted AIDS risk inventory (ACASI-ARI)]. FINDINGS The rates of opioid-negative urine tests over 24 weeks of treatment were significantly higher with [68.2%, 95% confidence interval (CI) = 65-71] than without behavioral counseling (59.2%, 95% CI = 56-62, P < 0.001) and with (71.0%, 95% CI = 68-74) than without ACB (56.4%, 95% CI = 53-59, P < 0.001); interaction effects between and among behavioral interventions and time were not statistically significant. Scores on ACASI-ARI decreased significantly from baseline across all treatment groups (P < 0.001) and did not differ significantly with or without behavioral counseling (P = 0.099) or with or without ACB (P = 0.339). CONCLUSIONS Providing opioid-dependent patients in Muar, Malaysia with buprenorphine-naloxone and physician management plus behavioral counseling or abstinence-contingent buprenorphine-naloxone (ACB) resulted in greater reductions of opioid use compared with providing buprenorphine-naloxone and physician management without behavioral counseling or ACB.
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Affiliation(s)
- Richard S Schottenfeld
- Department of Psychiatry and Behavioral Sciences, Howard University College of Medicine, Washington, DC, USA
| | - Marek C Chawarski
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
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Liu Y, Liu N, Shen W, Li L, Zhou W, Xu L. The Abuse Characteristics of Amphetamine-Type Stimulants in Patients Receiving Methadone Maintenance Treatment and Buprenorphine Maintenance Treatment. DRUG DESIGN DEVELOPMENT AND THERAPY 2021; 15:2109-2116. [PMID: 34040349 PMCID: PMC8140901 DOI: 10.2147/dddt.s305226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 04/20/2021] [Indexed: 11/30/2022]
Abstract
Objective The purpose of this study was to retrospectively investigate the abuse characteristics of amphetamine-type stimulants (ATS) in patients receiving methadone maintenance treatment (MMT) and buprenorphine maintenance treatment (BMT). Methods A total of 58 MMT and 51 BMT patients abusing ATS were recruited from the drug maintenance treatment clinic of Ningbo Addiction Research and Treatment Center from January 2018 to December 2019. They were assessed using the amphetamine abuse questionnaire (AAQ), addiction severity index (ASI) and Barratt impulsiveness scale (BIS). Moreover, 40 MMT control patients, 40 BMT control patients and 20 healthy controls were also assessed using the BIS. All information was collected using the amphetamine abuse questionnaire (AAQ), Chinese version of addiction severity index (ASI-C) and Chinese version of Barratt impulsiveness scale (BIS-C) conducted by qualified psychologists. Results The interval of amphetamine use in the MMT group was shorter than the BMT group (P < 0.05). The drug use subscale score of ASI was higher in the MMT group than the BMT group (P < 0.05). The respective and total scores of attentional impulsiveness, motor impulsiveness and non-planning impulsiveness in BIS in the MMT group were all higher than the MMT control group (P < 0.05). The scores of motor impulsiveness and non-planning impulsiveness in the BMT group were higher than the BMT control group (P < 0.05). The respective and total scores in BIS in the MMT control group and the BMT control group were all higher than those in the healthy controls. Conclusion The patients showing amphetamine abuse in maintenance therapy had a greater impulsiveness than those having other simple maintenance treatments, and patients under MMT may be more addicted to amphetamines in comparison with those having BMT.
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Affiliation(s)
- Yue Liu
- Department of Academic Research, Ningbo Kangning Hospital, Key Laboratory of Addiction Research of Zhejiang Province, Ningbo, 315201, People's Republic of China
| | - Nina Liu
- Department of Basic Medicine, Ningbo College of Health Sciences, Ningbo, 315100, People's Republic of China
| | - Wenwen Shen
- Department of Academic Research, Ningbo Kangning Hospital, Key Laboratory of Addiction Research of Zhejiang Province, Ningbo, 315201, People's Republic of China
| | - Longhui Li
- Department of Academic Research, Ningbo Kangning Hospital, Key Laboratory of Addiction Research of Zhejiang Province, Ningbo, 315201, People's Republic of China
| | - Wenhua Zhou
- Department of Academic Research, Ningbo Kangning Hospital, Key Laboratory of Addiction Research of Zhejiang Province, Ningbo, 315201, People's Republic of China
| | - Leiting Xu
- Department of Basic Medicine, Ningbo University School of Medicine, Ningbo, 315211, People's Republic of China
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Patnode CD, Perdue LA, Rushkin M, Dana T, Blazina I, Bougatsos C, Grusing S, O'Connor EA, Fu R, Chou R. Screening for Unhealthy Drug Use: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2020; 323:2310-2328. [PMID: 32515820 DOI: 10.1001/jama.2019.21381] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
IMPORTANCE Illicit drug use is among the most common causes of preventable morbidity and mortality in the US. OBJECTIVE To systematically review the literature on screening and interventions for drug use to inform the US Preventive Services Task Force. DATA SOURCES MEDLINE, PubMed, PsycINFO, Embase, and Cochrane Central Register of Controlled Trials through September 18, 2018; literature surveillance through September 21, 2019. STUDY SELECTION Test accuracy studies to detect drug misuse and randomized clinical trials of screening and interventions to reduce drug use. DATA EXTRACTION AND SYNTHESIS Critical appraisal and data abstraction by 2 reviewers and random-effects meta-analyses. MAIN OUTCOMES AND MEASURES Sensitivity, specificity, drug use and other health, social, and legal outcomes. RESULTS Ninety-nine studies (N = 84 206) were included. Twenty-eight studies (n = 65 720) addressed drug screening accuracy. Among adults, sensitivity and specificity of screening tools for detecting unhealthy drug use ranged from 0.71 to 0.94 and 0.87 to 0.97, respectively. Interventions to reduce drug use were evaluated in 52 trials (n = 15 659) of psychosocial interventions, 7 trials (n = 1109) of opioid agonist therapy, and 13 trials (n = 1718) of naltrexone. Psychosocial interventions were associated with increased likelihood of drug use abstinence (15 trials, n = 3636; relative risk [RR], 1.60 [95% CI, 1.24 to 2.13]; absolute risk difference [ARD], 9% [95% CI, 5% to 15%]) and reduced number of drug use days (19 trials, n = 5085; mean difference, -0.49 day in the last 7 days [95% CI, -0.85 to -0.13]) vs no psychosocial intervention at 3- to 4-month follow-up. In treatment-seeking populations, opioid agonist therapy and naltrexone were associated with decreased risk of drug use relapse (4 trials, n = 567; RR, 0.75 [95% CI, 0.59 to 0.82]; ARD, -35% [95% CI, -67% to -3%] and 12 trials, n = 1599; RR, 0.73 [95% CI, 0.62 to 0.85]; ARD, -18% [95% CI, -26% to -10%], respectively) vs placebo or no medication. While evidence on harms was limited, it indicated no increased risk of serious adverse events. CONCLUSIONS AND RELEVANCE Several screening instruments with acceptable sensitivity and specificity are available to screen for drug use, although there is no direct evidence on the benefits or harms of screening. Pharmacotherapy and psychosocial interventions are effective at improving drug use outcomes, but evidence of effectiveness remains primarily derived from trials conducted in treatment-seeking populations.
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Affiliation(s)
- Carrie D Patnode
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Leslie A Perdue
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Megan Rushkin
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Tracy Dana
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Ian Blazina
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Christina Bougatsos
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Sara Grusing
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Elizabeth A O'Connor
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Rongwei Fu
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
- School of Public Health, Oregon Health & Science University-Portland State University, Portland
| | - Roger Chou
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
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Bjornestad J, McKay JR, Berg H, Moltu C, Nesvåg S. How often are outcomes other than change in substance use measured? A systematic review of outcome measures in contemporary randomised controlled trials. Drug Alcohol Rev 2020; 39:394-414. [PMID: 32147903 DOI: 10.1111/dar.13051] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 01/21/2020] [Accepted: 02/11/2020] [Indexed: 11/27/2022]
Abstract
ISSUES Recovery is a theoretical construct and empirical object of inquiry. The aim was to review whether outcome measures used in randomised controlled trials of drug treatment reflect a comprehensive conceptualisation of recovery. APPROACH Systematic review using the following databases: Cochrane Database of Systematic Reviews, Cochrane Controlled Register of Trials, Database of Abstracts of Reviews of Effect, Web of Science, MEDLINE, Embase and PsycINFO. Search returned 6556 original articles and 504 met the following inclusion criteria: randomised controlled trial in English-language peer-reviewed journal; sample meets criteria for drug dependence or drug use disorder; reports non-substance use treatment outcomes. Review protocol registration: PROSPERO (CRD42018090064). KEY FINDINGS 3.8% of the included studies had a follow up of 2 years or more. Withdrawal/craving was present in 31.1% of short-term versus 0% of long-term studies. Social functioning in 8% of short-term versus 36.8% of long-term studies. Role functioning (0.9 vs. 26.3%), risk behaviour (15.6 vs. 36.8%) and criminality (3.8 vs. 21.1%) followed a similar pattern. Housing was not examined short-term and unregularly long-term (2.0%). 'Use of health-care facilities', clinical psychological, behavioural factors were frequently reported. Physiological or somatic health (15.2 vs. 10.5%), motivation (14.2 vs. 15.8%) and quality of life (7.1 vs. 0%) were less frequently reported. CONCLUSION The short time interval of the follow up and lack of information on relevant factors in recovery prevents the development of evidence-based approaches to improve these factors. Particularly, measures of social and role functioning should be added to reflect an adequate conceptualisation of recovery.
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Affiliation(s)
- Jone Bjornestad
- Department of Social Studies, Faculty of Social Sciences, University of Stavanger, Stavanger, Norway
- Department of Psychiatry, District General Hospital of Førde, Førde, Norway
| | - James R McKay
- Centre for Alcohol and Drug Research, Stavanger University Hospital, Stavanger, Norway
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Henrik Berg
- Centre for the Study of the Sciences and the Humanities, University of Bergen, Bergen, Norway
| | - Christian Moltu
- Department of Psychiatry, District General Hospital of Førde, Førde, Norway
| | - Sverre Nesvåg
- Centre for Alcohol and Drug Research, Stavanger University Hospital, Stavanger, Norway
- Department of Public Health, Faculty of Health Sciences, Stavanger, Norway
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Self-efficacy Mediates Perceived Benefits and Barriers of Adherence of Heroin-dependent Patients to Methadone for Addiction Treatment: A Health Belief Model Study. J Addict Med 2020; 14:e110-e117. [PMID: 32142052 DOI: 10.1097/adm.0000000000000640] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Although methadone for addiction treatment (MAT) has been widely used in China, the low adherence rate in MAT clinics poses a great challenge. We aimed to investigate the factors related to the adherence of heroin-dependent patients to MAT based on the Health Belief Model (HBM) in Sichuan, China. METHODS A cross-sectional structured interview was conducted between August and November 2018. Stratified multi-stage sampling was carried out. A total of 581 participants were enrolled from 5 clinics and completed the face-to-face structured interview. Univariate, adjusted logistic regression, multivariate logistic regression analysis and the structural equation modeling (SEM) were employed to explore the association between constructs of HBM and adherence to MAT among heroin-dependent patients. RESULTS The adherence rate of MAT was 79.3% in the past 6 months. Among all constructs of HBM, self-efficacy (AOR: 1.16, 95% CI: 1.10, 1.22), perceived benefits (AOR: 1.05, 95% CI: 1.00, 1.10) and perceived barriers (AOR: 0.87, 95% CI: 0.77, 0.98) were associated with adherence to MAT. Self-efficacy was directly associated with adherence to MAT (β = 0.347, P < 0.05). Perceive benefits (β = 0.276, P < 0.01) and perceived barriers (β = -0.241, P < 0.05) were directly associated with self-efficacy. However, perceived benefits (β = 0.096, P < 0.01) and perceived barriers (β = -0.084, P < 0.01) were only indirectly associated with adherence to MAT. CONCLUSION The adherence of heroin-dependent patients to MAT can be explained by self-efficacy, perceived benefits and barriers. Self-efficacy plays a significant role as a mediating variable. Future interventions should be considered to improve patients' self-efficacy to MAT.
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Dong R, Wang H, Li D, Lang L, Gray F, Liu Y, Laffont CM, Young M, Jiang J, Liu Z, Learned SM. Pharmacokinetics of Sublingual Buprenorphine Tablets Following Single and Multiple Doses in Chinese Participants With and Without Opioid Use Disorder. Drugs R D 2020; 19:255-265. [PMID: 31197606 PMCID: PMC6738359 DOI: 10.1007/s40268-019-0277-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Two phase I studies assessed the pharmacokinetics of buprenorphine, its metabolite norbuprenorphine, and naloxone following administration of buprenorphine/naloxone sublingual tablets in Chinese participants. Methods In the first phase I, open-label, single ascending-dose (SAD) study, 82 opioid-naïve volunteers received a single buprenorphine/naloxone dose ranging from 2 mg/0.5 mg to 24 mg/6 mg while under naltrexone block. In a second phase I, open-label, multiple ascending-dose (MAD) study, 27 patients with opioid dependence in withdrawal received buprenorphine/naloxone doses of either 16 mg/4 mg or 24 mg/6 mg for 9 consecutive days. Serial blood samples were collected after a single dose (SAD study) and at steady-state (MAD study). Pharmacokinetic parameters were calculated using non-compartmental analysis. Safety assessments included adverse events monitoring and laboratory tests. Results The pharmacokinetic profiles of buprenorphine and naloxone were consistent between single- and multiple-dose studies. Peak plasma concentrations (Cmax) were reached early for buprenorphine (0.75–1.0 h) and naloxone (0.5 h), supporting rapid absorption. In the SAD study, increases in plasma exposures to buprenorphine and naloxone were less than dose proportional, in line with previous observations in Western populations. Buprenorphine-to-naloxone ratios for Cmax and area under the curve (AUC) were constant over the dose range investigated and also consistent with Western populations data. Steady state was reached within 7 days of daily dosing, with slight accumulation over repeated doses. No serious adverse events were observed. Conclusions The present data suggest that buprenorphine/naloxone pharmacokinetic profiles in Chinese participants are consistent, overall, with those in Western populations, supporting no differences in dosing. Clinical Trial Registration The protocols were registered on the official website of the China Food and Drug Administration (CFDA): http://www.chinadrugtrials.org.cn/; Registration numbers CTR20132963 (RB-CN-10-0012), CTR20140153 (RB-CN-10-0015). Electronic supplementary material The online version of this article (10.1007/s40268-019-0277-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ruihua Dong
- Department of Clinical Pharmacology, 307 Hospital of PLA, Beijing, 100071, China
| | - Hongyun Wang
- Clinical Pharmacology Center, Peking Union Medical College Hospital & Beijing Key Laboratory of Clinical PK and PD Investigation for Innovative Drugs, Beijing, 100730, China
| | - Dandan Li
- Department of Clinical Pharmacology, 307 Hospital of PLA, Beijing, 100071, China
| | - Liwei Lang
- Clinical Pharmacology Center, Peking Union Medical College Hospital & Beijing Key Laboratory of Clinical PK and PD Investigation for Innovative Drugs, Beijing, 100730, China
| | - Frank Gray
- Indivior PLC, 215 Bath Road, Slough, England, SL1 4AA, UK
| | - Yongzhen Liu
- Indivior PLC, 215 Bath Road, Slough, England, SL1 4AA, UK.
| | | | - Malcolm Young
- Indivior PLC, 215 Bath Road, Slough, England, SL1 4AA, UK
| | - Ji Jiang
- Clinical Pharmacology Center, Peking Union Medical College Hospital & Beijing Key Laboratory of Clinical PK and PD Investigation for Innovative Drugs, Beijing, 100730, China
| | - Zeyuan Liu
- Department of Clinical Pharmacology, 307 Hospital of PLA, Beijing, 100071, China
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16
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COPD and asthma in patients with opioid dependency: a cross-sectional study in primary care. NPJ Prim Care Respir Med 2020; 30:4. [PMID: 31937808 PMCID: PMC6959319 DOI: 10.1038/s41533-019-0161-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 11/29/2019] [Indexed: 11/15/2022] Open
Abstract
Patients treated for drug addiction have high asthma and COPD prevalence rates. The relative contributions of cigarette smoking, smoking intensity and possible smoking of other substances has not been described. We aimed to describe the prevalence and determinants of asthma and COPD in patients prescribed methadone as opioid substitution therapy (OST). In a cross-sectional study of an anonymised patient-level primary care dataset of UK inner-city general practices (n = 46), 321,395 patients aged ≥18 years were identified. A total of 676 (0.21%) had a record of a methadone ever issued in primary care. The association between respiratory disease and methadone prescribing was examined using logistic regression. Models were adjusted for potential effects of clustering by practice. A total of 97.3% of patients prescribed methadone were cigarette smokers, either current (81.2%) or ex-smokers (16.1%). The prevalences of asthma and COPD were higher in methadone patients (14.2% and 12.4%, respectively) compared to non-methadone patients (4.4% and 1.1%, respectively). Methadone was an independent determinant of asthma, adjusting for smoking status (OR 3.21; 95% CI: 2.52, 4.10) or for smoking intensity (3.08; 2.27, 4.19), and of COPD, adjusting for smoking status (6.00; 4.61, 7.80) or for smoking intensity (5.80; 4.12, 8.17). COPD and asthma prevalence were substantially higher in those prescribed methadone compared to those never prescribed methadone. Prescription of methadone was an independent predictor for both COPD and asthma, even after adjustment for smoking status and smoking intensity. Possible explanations include confounding by association with smoking of heroin or crack cocaine, both of which may have a causal association with COPD and asthma.
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17
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Dennis BB, Sanger N, Bawor M, Naji L, Plater C, Worster A, Woo J, Bhalerao A, Baptist-Mohseni N, Hillmer A, Rice D, Corace K, Hutton B, Tugwell P, Thabane L, Samaan Z. A call for consensus in defining efficacy in clinical trials for opioid addiction: combined results from a systematic review and qualitative study in patients receiving pharmacological assisted therapy for opioid use disorder. Trials 2020; 21:30. [PMID: 31907000 PMCID: PMC6945391 DOI: 10.1186/s13063-019-3995-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 12/13/2019] [Indexed: 11/23/2022] Open
Abstract
Background Given the complex nature of opioid addiction treatment and the rising number of available opioid substitution and antagonist therapies (OSAT), there is no ‘gold standard’ measure of treatment effectiveness, and each successive trial measures a different set of outcomes which reflect success in arbitrary or opportune terms. We sought to describe the variation in current outcomes employed across clinical trials for opioid addiction, as well as determine whether a discrepancy exists between the treatment targets that patients consider important and how treatment effectiveness is measured in the literature. Methods We searched nine commonly used databases (e.g., EMBASE, MEDLINE) from inception to August 1, 2015. Outcomes used across trials were extracted and categorized according to previously established domains. To evaluate patient-reported goals of treatment, semi-structured interviews were conducted with 18 adults undergoing methadone treatment. Results We identified 60 trials eligible for inclusion. Once outcomes were categorized into eight broad domains (e.g., abstinence/substance abuse), we identified 21 specific outcomes with furthermore 53 subdomains and 118 measurements. Continued opioid use and treatment retention were the most commonly reported measures (46%, n = 28). The majority of patients agreed that abstinence from opioids was a primary goal in their treatment, although they also stressed goals under-reported in clinical trials. Conclusions There is inconsistency in the measures used to evaluate the effectiveness of OSATs. Individual and population level decision making is being guided by a standard of effect considered useful to researchers yet in direct conflict with what patients deem important. Trial registration PROSPERO, CRD42013006507.
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Affiliation(s)
- Brittany B Dennis
- McMaster University Internal Medicine Residency Program, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Nitika Sanger
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Monica Bawor
- McMaster University Internal Medicine Residency Program, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Leen Naji
- Department of Family Medicine Residency Program, Michael G. Degroote School of Medicine, McMaster University, Hamilton, Canada
| | - Carolyn Plater
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada
| | - Andrew Worster
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,Department of Medicine, Hamilton General Hospital, Hamilton, Canada
| | - Julia Woo
- University of Toronto Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Anuja Bhalerao
- University of Toronto Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Natasha Baptist-Mohseni
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada
| | - Alannah Hillmer
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada
| | - Danielle Rice
- Faculty of Science, Department of Psychology, McGill University, Montreal, Canada.,Center for Practice Changing Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kim Corace
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,University of Ottawa Institute of Mental Health Research, Ottawa, ON, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tugwell
- WHO Collaborating Centre for Knowledge Translation and Health Technology Assessment in Health Equity, Bruyère Research Institute, Ottawa, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,Centre for Evaluation of Medicine, Hamilton, Canada.,System Linked Research Unit, Hamilton, Canada
| | - Zainab Samaan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada. .,Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada. .,Population Genomics Program, Chanchlani Research Center, McMaster University, Hamilton, Canada.
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Ruzilawati AB, Deeza-Syafiqah MS, Ahmad I, Shamsuddin S, Gan SH, Vicknasingam BK. Influence of dopaminergic system gene polymorphisms on mixed amphetamine-type stimulants and opioid dependence in Malaysian Malays. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2019. [DOI: 10.1186/s43042-019-0005-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Wang X, Jiang H, Zhao M, Li J, Gray F, Sheng L, Li Y, Li X, Ling W, Li W, Hao W. Treatment of opioid dependence with buprenorphine/naloxone sublingual tablets: A phase 3 randomized, double-blind, placebo-controlled trial. Asia Pac Psychiatry 2019; 11:e12344. [PMID: 30460781 DOI: 10.1111/appy.12344] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 09/21/2018] [Indexed: 02/05/2023]
Abstract
INTRODUCTION The purpose of the study is to evaluate the efficacy and safety of buprenorphine/naloxone sublingual tablets for the treatment of opioid dependence in Chinese adults. METHODS This multicenter, double-blind, placebo-controlled study included four periods: induction (3-5 days), stabilization (7-21 days), randomization/treatment (6 weeks), and postmedication follow-up (1 week). A total of 442 participants with opioid dependence were enrolled; 260 were randomized to buprenorphine/naloxone or placebo. The primary outcome was retention in treatment, defined as the time from randomization to treatment completion or treatment failure. Secondary outcomes included maximum consecutive days of abstinence from opioids, self-reported craving and opioid withdrawal symptoms, and urine drug screen results. Safety assessments included adverse event reporting, electrocardiograms, clinical laboratory tests, vital signs, and prior/concomitant medications. RESULTS The median treatment retention time (95% confidence internal) with buprenorphine/naloxone was 32 days (26-38) versus 6 days (5-8) for placebo, with a Cox hazard ratio of 0.28 (95% confidence interval, 0.21-0.38; P < 0.0001). The median maximum consecutive days of abstinence (95% confidence interval) was: buprenorphine/naloxone, 21 days (26-38); placebo, 5 days (5-8) with a Cox hazard ratio of 0.38 (95% confidence interval, 0.25-0.60; P < 0.0001). Withdrawal and craving symptoms were significantly milder with buprenorphine/naloxone versus placebo (P < 0.001). Urine drug screen results indicated significantly lower opioid usage in the buprenorphine/naloxone group compared with placebo (P < 0.001). The most commonly reported adverse events in the buprenorphine/naloxone group during treatment were aspartate aminotransferase increased and nasopharyngitis. DISCUSSION Efficacy and safety results from this clinical trial support a positive benefit-risk ratio for buprenorphine/naloxone sublingual tablet use in the treatment of an opioid-dependent Chinese population.
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Affiliation(s)
- XuYi Wang
- The Second Xiangya Hospital of Central South University, Changsha, China
| | - Haifeng Jiang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Min Zhao
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Li
- West China Hospital of Sichuan University, Sichuan Sheng, China
| | | | - Lixia Sheng
- Beijing An Ding Hospital, Capital Medical University, Beijing, China
| | - Yi Li
- Wuhan Mental Health Center, Wuhan, China
| | | | - Walter Ling
- University of California at Los Angeles, Los Angeles, CA, USA
| | - Wei Li
- Medical Research & Biometrics Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing, China
| | - Wei Hao
- The Second Xiangya Hospital of Central South University, Changsha, China
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Atomoxetine for amphetamine-type stimulant dependence during buprenorphine treatment: A randomized controlled trial. Drug Alcohol Depend 2018; 186:130-137. [PMID: 29573648 PMCID: PMC5911201 DOI: 10.1016/j.drugalcdep.2018.01.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 01/24/2018] [Accepted: 01/24/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Amphetamine type stimulants (ATS) use is highly prevalent and frequently co-occurs with opioid dependence in Malaysia and Asian countries. No medications have established efficacy for treating ATS use disorder. This study evaluated the safety, tolerability, and potential efficacy of atomoxetine for treating ATS use disorder. METHODS Participants with opioid and ATS dependence (N = 69) were enrolled in a pilot, double-blind, placebo-controlled randomized clinical trial; all received buprenorphine/naloxone and behavioral counseling and were randomized to atomoxetine 80 mg daily (n = 33) or placebo (n = 33). The effect size of the between-group difference on the primary outcome, proportion of ATS-negative urine tests, was estimated using Cohen's d for the intention-to-treat (ITT) sample and for higher adherence subsample (≥60 days of atomoxetine or placebo ingestion). RESULTS Participants were all male with mean (SD) age 39.4 (6.8) years. The proportion of ATS-negative urine tests was higher in atomoxetine- compared to placebo-treated participants: 0.77 (0.63-0.91) vs. 0.67 (0.53-0.81, d = 0.26) in the ITT sample and 0.90 (0.75-1.00) vs. 0.64 (0.51-0.78, d = 0.56) in the higher adherence subsample. The proportion of days abstinent from ATS increased from baseline in both groups (p < 0.001) and did not differ significantly between atomoxetine- and placebo-treated participants (p = 0.42). Depressive symptoms were reduced from baseline in both groups (p < 0.02) with a greater reduction for atomoxetine- than placebo-treated participants (p < 0.02). There were no serious adverse events or adverse events leading to medication discontinuation. CONCLUSIONS The findings support clinical tolerability and safety and suggest potential efficacy of atomoxetine for treating ATS use disorder in this population.
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McGee MD. The Optimal Management of Opioid Use Disorder: Leveraging Advances in Addiction Psychopharmacology to Enhance Treatment Outcomes. Psychiatr Ann 2018. [DOI: 10.3928/00485713-20180417-01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Affiliation(s)
- David C Lott
- Department of Psychiatry, University of Illinois College of Medicine, Chicago, IL 60612, USA.
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Velander JR. Suboxone: Rationale, Science, Misconceptions. Ochsner J 2018; 18:23-29. [PMID: 29559865 PMCID: PMC5855417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023] Open
Affiliation(s)
- Jennifer R Velander
- Department of Psychiatry, Ochsner Clinic Foundation, New Orleans, LA and The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
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Lander L, Chiasson-Downs K, Andrew M, Rader G, Dohar S, Waibogha K. Yoga as an Adjunctive Intervention to Medication-Assisted Treatment with Buprenorphine+Naloxone. ACTA ACUST UNITED AC 2017; 9:354. [PMID: 30820364 PMCID: PMC6390289 DOI: 10.4172/2155-6105.1000354] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objective According to the CDC, 2.6 million people in the United States have an opioid use disorder and drug overdose is the leading cause of accidental death. Opioids are involved in 63% of overdose deaths. It is imperative that we identify evidence based treatments to stem the tide of this epidemic. This pilot study serves to explore the feasibility and effectiveness of Yoga as an adjunctive intervention for individuals with opioid use disorder in active medication-assisted treatment (MAT). Methods Participants (N=26) were recruited from a buprenorphine/naloxone MAT program to participate in this study. 13 participants engaged in a 12 week adjunctive yoga intervention while remaining in treatment as usual (TAU) MAT. 13 matched controls were recruited and remained in TAU MAT. Both groups were evaluated at baseline, 45 days and 90 days for changes in craving for opioids, treatment retention, relapse rates, sleep, and symptoms of anxiety and perceived stress. Results A two-way treatment by time analysis of variance was performed using a mixed effects model. The treatment by follow-up time interaction effect was significant for perceived stress (p=0.026) indicating that the yoga intervention had a larger effect than TAU (MAT). Changes in perceived stress decreased significantly over time in both the yoga intervention group and the TAU MAT matched control group. Conclusion This pilot study indicated strong evidence for Yoga being an effective adjunctive treatment to MAT TAU in reducing perceived stress. Further research with a larger population is needed to determine impact on other mental health symptoms and relapse and retention rates.
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Affiliation(s)
- Laura Lander
- Department of Behavioral Medicine and Psychiatry, West Virginia University, Morgantown, USA
| | | | - Michael Andrew
- National Institute for Occupational Safety and Health, Morgantown, USA
| | - Gerald Rader
- School of Medicine West Virginia University, Morgantown, USA
| | - Sheena Dohar
- Department of Behavioral Medicine and Psychiatry, West Virginia University, Morgantown, USA
| | - Kimberly Waibogha
- Department of Behavioral Medicine and Psychiatry, West Virginia University, Morgantown, USA
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The Availability of Ancillary Counseling in the Practices of Physicians Prescribing Buprenorphine. J Addict Med 2017; 10:352-6. [PMID: 27504926 DOI: 10.1097/adm.0000000000000247] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We set out to examine physicians' perceptions of the provision of ancillary services for opioid dependent patients receiving buprenorphine. METHODS An e-mail invitation describing the study was sent out by the American Society of Addiction Medicine to its membership (approximately 3700 physicians) and other entities (for a total of approximately 7000 e-mail addresses). E-mail recipients were invited to participate in a research study funded by the National Institutes on Drug Abuse involving completion of an online survey; 346 physicians completed the survey. RESULTS The majority of the 346 respondents were internal or family medicine (37%), or addiction medicine providers (30%), who were practicing in urban (57%) or suburban settings (27%). Most respondents reported either offering (66%) or referring patients for ancillary counseling (31%). Interventions that were most frequently offered or referrals provided were individual counseling (51%) and self-help groups (63%), respectively. Counseling availability differed significantly by provider specialization for any, individual, group, family or couples, and self-help groups. CONCLUSIONS Generally, respondents reported compliance with ancillary counseling requirements for buprenorphine treatment of opioid use disorder. In addition to examining the efficacy of a variety of ancillary counseling services for patients receiving opioid agonist treatment, further research should examine physicians' attitudes toward the role of such counseling in buprenorphine treatment. Although the study sample was relatively large, the generalizability of the findings is unclear, suggesting that further investigation of the availability of ancillary counseling in buprenorphine treatment among a larger nationally representative sample of providers may be warranted.
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Dayal P, Balhara YPS. A naturalistic study of predictors of retention in treatment among emerging adults entering first buprenorphine maintenance treatment for opioid use disorders. J Subst Abuse Treat 2017; 80:1-5. [DOI: 10.1016/j.jsat.2017.06.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 06/09/2017] [Accepted: 06/13/2017] [Indexed: 10/19/2022]
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Abstract
Opioid use disorders (OUDs) have long been a global problem, but the prevalence rates have increased over 20 years to epidemic proportions in the US, with concomitant increases in morbidity and all-cause mortality, but especially opioid overdose. These increases are in part attributable to a several-fold expansion in the prescription of opioid pain medications over the same time period. Opioid detoxification and psychosocial treatments alone have each not yielded sufficient efficacy for OUD, but μ-opioid receptor agonist, partial agonist, and antagonist medications have demonstrated the greatest overall benefit in OUD treatment. Buprenorphine, a μ-opioid receptor partial agonist, has been used successfully on an international basis for several decades in sublingual tablet and film preparations for the treatment of OUD, but the nature of formulation, which is typically self-administered, renders it susceptible to nonadherence, diversion, and accidental exposure. This article reviews the clinical trial data for novel buprenorphine delivery systems in the form of subcutaneous depot injections, transdermal patches, and subdermal implants for the treatment of OUD and discusses both the clinical efficacy of longer-acting formulations through increasing consistent medication exposure and their potential utility in reducing diversion. These new delivery systems also offer new dosing opportunities for buprenorphine and strategies for dosing intervals in the treatment of OUD.
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Affiliation(s)
- Richard N Rosenthal
- Department of Psychiatry, Addiction Institute at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York
| | - Viral V Goradia
- Department of Psychiatry, Upstate Medical University, Syracuse, NY, USA
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Dunlop AJ, Brown AL, Oldmeadow C, Harris A, Gill A, Sadler C, Ribbons K, Attia J, Barker D, Ghijben P, Hinman J, Jackson M, Bell J, Lintzeris N. Effectiveness and cost-effectiveness of unsupervised buprenorphine-naloxone for the treatment of heroin dependence in a randomized waitlist controlled trial. Drug Alcohol Depend 2017; 174:181-191. [PMID: 28371689 DOI: 10.1016/j.drugalcdep.2017.01.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 12/19/2016] [Accepted: 01/09/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Access to opioid agonist treatment can be associated with extensive waiting periods with significant health and financial burdens. This study aimed to determine whether patients with heroin dependence dispensed buprenorphine-naloxone weekly have greater reductions in heroin use and related adverse health effects 12-weeks after commencing treatment, compared to waitlist controls and to examine the cost-effectiveness of this strategy. METHODS An open-label waitlist RCT was conducted in an opioid treatment clinic in Newcastle, Australia. Fifty patients with DSM-IV-TR heroin dependence (and no other substance dependence) were recruited. The intervention group (n=25) received take-home self-administered sublingual buprenorphine-naloxone weekly (mean dose, 22.7±5.7mg) and weekly clinical review. Waitlist controls (n=25) received no clinical intervention. The primary outcome was heroin use (self-report, urine toxicology verified) at weeks four, eight and 12. The primary cost-effectiveness outcome was incremental cost per additional heroin-free-day. RESULTS Outcome data were available for 80% of all randomized participants. Across the 12-weeks, treatment group heroin use was on average 19.02days less/month (95% CI -22.98, -15.06, p<0.0001). A total 12-week reduction in adjusted costs including crime of $A5,722 (95% CI 3299, 8154) in favor of treatment was observed. Excluding crime, incremental cost per heroin-free-day gained from treatment was $A18.24 (95% CI 4.50, 28.49). CONCLUSION When compared to remaining on a waitlist, take-home self-administered buprenorphine-naloxone treatment is associated with significant reductions in heroin use for people with DSM-IV-TR heroin dependence. This cost-effective approach may be an efficient strategy to enhance treatment capacity.
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Affiliation(s)
- Adrian J Dunlop
- Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia; School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia; Centre for Brain and Mental Health, University of Newcastle and Hunter Medical Research Institute, Newcastle, NSW, Australia.
| | - Amanda L Brown
- Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia; School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia; Centre for Brain and Mental Health, University of Newcastle and Hunter Medical Research Institute, Newcastle, NSW, Australia.
| | - Christopher Oldmeadow
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia; Clinical Research Design, IT and Statistical Support (CRεDITSS) Unit, Hunter Medical Research Institute, Newcastle, NSW, Australia.
| | - Anthony Harris
- Centre for Health Economics, Monash University, Clayton, Victoria, Australia.
| | - Anthony Gill
- Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia; School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia.
| | - Craig Sadler
- Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia; School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia; Alcohol and Drug Unit, Calvary Mater Newcastle, Waratah, NSW, Australia.
| | - Karen Ribbons
- Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia.
| | - John Attia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia; Clinical Research Design, IT and Statistical Support (CRεDITSS) Unit, Hunter Medical Research Institute, Newcastle, NSW, Australia; Department of Medicine, John Hunter Hospital, Hunter New England Local Health District, New Lambton Heights, NSW, Australia.
| | - Daniel Barker
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia.
| | - Peter Ghijben
- Centre for Health Economics, Monash University, Clayton, Victoria, Australia.
| | - Jennifer Hinman
- Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia.
| | - Melissa Jackson
- Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia.
| | - James Bell
- Addictions Department, Institute of Psychiatry, Kings College London, London, United Kingdom; Drug Health Services, Sydney Local Health District, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.
| | - Nicholas Lintzeris
- Drug and Alcohol Services, South East Sydney Local Health District, Surry Hills, NSW, Australia; Central Clinical School,Discipline of Addiction Medicine, University of Sydney, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.
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Le Roux C, Tang Y, Drexler K. Alcohol and Opioid Use Disorder in Older Adults: Neglected and Treatable Illnesses. Curr Psychiatry Rep 2016; 18:87. [PMID: 27488204 DOI: 10.1007/s11920-016-0718-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The purpose of this article is to provide an overview of alcohol use disorder (AUD) and opioid use disorder (OUD) in older adults for general psychiatrists. The rapid growth of the geriatric population in the USA has wide-ranging implications as the baby boomer generation ages. Various types of substance use disorders (SUDs) are common in older adults, and they often take a greater toll on affected older adults than on younger adults. Due to multiple reasons, SUDs in older adults are often under-reported, under-detected, and under-treated. Older adults often use substances, which leads to various clinical problems. Space limitations prevents a comprehensive review; therefore, we primarily focus on alcohol use disorder and the problem of opioid use disorder, with more emphasis given to the latter, because the opioid use epidemic in the USA has gained much attention. We reviewed the literature on the topics, integrated across geriatric psychiatry, addiction psychiatry, research, and national trends. We discuss unique vulnerabilities of older adults to SUDs with regard to management of SUDs in older adults, medication-assisted treatment (MAT), and psychosocial treatments. We encourage general psychiatrists to raise their awareness of SUDs in older adults and to provide brief intervention or referral for further assessment.
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Affiliation(s)
- Christoffel Le Roux
- Atlanta VA Medical Center, Mental Health Service Line (116), 1670 Clairmont Road, Atlanta, GA, 30033, USA.,Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, USA
| | - Yilang Tang
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive NE, Atlanta, GA, 30329, USA
| | - Karen Drexler
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, USA. .,Addictive Disorders, VA Central Office, Washington, D.C., Atlanta VA Medical Center, Mental Health Service Line (116), 1670 Clairmont Road, Atlanta, GA, 30033, USA.
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Desrosiers A, Chooi WT, Zaharim NM, Ahmad I, Mohd Yasin MA, Syed Jaapar SZ, Schottenfeld RS, Vicknasingam B, Chawarski MC. Emerging Drug Use Trends in Kelantan, Malaysia. J Psychoactive Drugs 2016; 48:218-26. [PMID: 27224011 DOI: 10.1080/02791072.2016.1185553] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The primarily rural and agrarian Kelantan province of Malaysia has high rates of drug use and is characterized by unique sociocultural factors. Combining qualitative and ethnographic methods, we investigated drug use and treatment needs of people who use drugs (PWUD) in rural areas of Kelantan. In February 2014, field visits, participant observation, and focus group discussions (FGDs) with 27 active PWUD were conducted in rural areas surrounding the capital city of Kelantan. The findings indicate a high prevalence of opiate and amphetamine type stimulants (ATS) use in these areas. FGD participants reported initiating drug use at early ages due to peer influences, to relieve boredom, to cope with problems, and a high saturation of villages with other PWUD was reported as a major contributor to their own continued drug use. They reported a trend of drug use initiation at younger ages and increased drug use among females. Participants were interested in treatment; however, their limited knowledge about treatment options and perceived limited availability of services were barriers to treatment seeking. Easy access to drugs, primarily from Thailand and facilitated by the use of mobile phones, resulted in an expanding prevalence of drug use that underscores the need to bolster education and prevention efforts and accessibility of treatment services in Kelantan.
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Affiliation(s)
- Alethea Desrosiers
- a Associate Research Scientist, Department of Psychiatry , Yale School of Medicine , New Haven , CT , USA
| | - Weng-Tink Chooi
- b Postdoctoral Associate, Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA & Lecturer , Advanced Medical and Dental Institute, Universiti Sains Malaysia , Penang , Malaysia
| | - Norzarina Mohd Zaharim
- c Associate Professor, School of Social Sciences , Universiti Sains Malaysia , Penang , Malaysia
| | - Imran Ahmad
- d Medical Lecturer, School of Medical Sciences , Universiti Sains Malaysia , Kelantan , Malaysia
| | - Mohd Azhar Mohd Yasin
- d Medical Lecturer, School of Medical Sciences , Universiti Sains Malaysia , Kelantan , Malaysia
| | - Sharifah Z Syed Jaapar
- d Medical Lecturer, School of Medical Sciences , Universiti Sains Malaysia , Kelantan , Malaysia
| | | | - Balasingam Vicknasingam
- f Associate Professor, Centre for Drug Research , Universiti Sains Malaysia , Penang , Malaysia
| | - Marek C Chawarski
- g Associate Professor, Department of Psychiatry , Yale School of Medicine , New Haven , CT , USA
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Mokri A, Chawarski MC, Taherinakhost H, Schottenfeld RS. Medical treatments for opioid use disorder in Iran: a randomized, double-blind placebo-controlled comparison of buprenorphine/naloxone and naltrexone maintenance treatment. Addiction 2016; 111:874-82. [PMID: 26639678 DOI: 10.1111/add.13259] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 11/03/2015] [Accepted: 11/25/2015] [Indexed: 11/30/2022]
Abstract
AIMS With the broad goals of developing a clinical research and training program and disseminating effective opioid use disorder treatments in Iran, this pilot clinical trial compared the effectiveness of oral naltrexone (NTX) and sublingual buprenorphine/naloxone (BNX). DESIGN Twelve-week single-site, two-group parallel randomized double-blind clinical trial. SETTING An out-patient clinical research program in Tehran, Iran. PARTICIPANTS Following medically assisted withdrawal, participants with opioid use disorder were assigned randomly to NTX (n = 51) or BNX (n = 51). INTERVENTION Medications were administered three times per week, double-blind, double-dummy for 12 weeks. All participants received weekly group drug counseling. MEASUREMENTS The primary outcome was initial duration of opioid abstinence verified by urine toxicology tests. Secondary outcomes included the number of opioid-negative urine tests, treatment retention and proportions with sustained, verified opioid-abstinence for 12 weeks. FINDINGS Mean [95% confidence interval (CI)] number of days of initial duration of verified abstinence was 28.8 (20.0-37.5) with BNX and 21.6 (14.4-28.7) with NTX (P = 0.205). The mean (95% CI) number of opioid-negative urine tests was 19.7 (17.7-21.6) with BNX and 15.4 (13.1-17.8) with NTX (P = 0.049). The mean (95% CI) number of days in treatment was 70.6 (63.6-77.7) with BNX versus 56.5 (47.8-65.3) with NTX (P = 0.013). The rate of sustained, 12-week opioid abstinence was 16% (8/51) in the BNX group and 8% (4/51) in the NTX group (P = 0.219). CONCLUSIONS Among patients with opioid use disorder in Iran, sublingual buprenorphine/naloxone was associated with a greater number of opioid-negative urine tests and treatment retention than oral naltrexone, but not significantly greater initial abstinence duration or proportions with sustained abstinence.
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Affiliation(s)
- Azarakhsh Mokri
- Iranian National Center for Addiction Studies and Tehran University of Medical Sciences, Tehran, Iran
| | - Marek C Chawarski
- Departments of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Hamidreza Taherinakhost
- Iranian National Center for Addiction Studies and Tehran University of Medical Sciences, Tehran, Iran
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Bizzarri JV, Casetti V, Sanna L, Maremmani AGI, Rovai L, Bacciardi S, Piacentino D, Conca A, Maremmani I. The newer Opioid Agonist Treatment with lower substitutive opiate doses is associated with better toxicology outcome than the older Harm Reduction Treatment. Ann Gen Psychiatry 2016; 15:34. [PMID: 27933094 PMCID: PMC5124303 DOI: 10.1186/s12991-016-0109-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 08/04/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Charge-free heroin use disorder treatment in Italy follows two main approaches, i.e., harm reduction treatment (HRT) strategy in community low-threshold facilities for drug addiction and opioid agonist treatment (OAT) in high-threshold facilities for opioid addiction, focusing on pharmacological maintenance according to the Dole and Nyswander strategy. We aimed to compare the impact of HRT and OAT on patient outcome, as assessed through negativity for drugs on about 1-year urinalyses. METHODS We examined retrospectively the urinalyses of HRT and OAT patients for which at least four randomly sampled urinalyses per month were available for about 1 year, during which patients were undergoing methadone or buprenorphine maintenance; urinalyses focused on heroin, cocaine, cannabinoids, and their metabolites. RESULTS Included were 189 HRT and 58 OAT patients. The latter were observed for a significantly longer period. There was a higher proportion of heroin- and cocaine-clean urinalyses in OAT patients, with cocaine-clean urinalyses discriminating best between the two groups. OAT patients were older, with longer dependence duration, more severe addiction history, and received lower methadone doses. Buprenorphine maintenance was more often associated with heroin-clean urinalyses. The higher the methadone doses, the lower were the percentage of heroin-clean urinalyses in HRT patients (negative correlation). CONCLUSIONS The OAT approach was related to higher recovery and polyabuse abstinence rates compared to the HRT approach, despite greater severity of substance use, psychiatric and physical comorbidities. Our results are consistent with the possibility to use lower maintenance opiate doses (after induction and stabilization in methadone treatment according to Dole and Nyswander methodology) in treating heroin addiction. This seemed to be impossible adopting the currently accepted HRT model.
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Affiliation(s)
| | | | - Livia Sanna
- Department of Psychiatry of Bolzano, Bolzano, Italy
| | - Angelo Giovanni Icro Maremmani
- Vincent P. Dole Dual Diagnosis Unit, Department of Neurosciences, Santa Chiara University Hospital, University of Pisa, Via Roma, 67 56100 Pisa, Italy ; AU-CNS-Association for the Application of Neuroscientific Knowledge to Social Aims, Pietrasanta, Italy
| | - Luca Rovai
- Vincent P. Dole Dual Diagnosis Unit, Department of Neurosciences, Santa Chiara University Hospital, University of Pisa, Via Roma, 67 56100 Pisa, Italy
| | - Silvia Bacciardi
- Vincent P. Dole Dual Diagnosis Unit, Department of Neurosciences, Santa Chiara University Hospital, University of Pisa, Via Roma, 67 56100 Pisa, Italy
| | | | | | - Icro Maremmani
- Vincent P. Dole Dual Diagnosis Unit, Department of Neurosciences, Santa Chiara University Hospital, University of Pisa, Via Roma, 67 56100 Pisa, Italy ; AU-CNS-Association for the Application of Neuroscientific Knowledge to Social Aims, Pietrasanta, Italy ; G De Lisio Institute of Behavioural Sciences, Pisa, Italy
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Dennis BB, Roshanov PS, Naji L, Bawor M, Paul J, Plater C, Pare G, Worster A, Varenbut M, Daiter J, Marsh DC, Desai D, Samaan Z, Thabane L. Opioid substitution and antagonist therapy trials exclude the common addiction patient: a systematic review and analysis of eligibility criteria. Trials 2015; 16:475. [PMID: 26489415 PMCID: PMC4618532 DOI: 10.1186/s13063-015-0942-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 09/03/2015] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Eligibility criteria that result in the exclusion of a substantial number of patients from randomized trials jeopardize the generalizability of treatment effect to much of the clinical population. This is important when evaluating opioid substitution and antagonist therapies (OSATs), especially given the challenges associated with treating the opioid-dependent population. We aimed to identify OSAT trials' eligibility criteria, quantify the percentage of the clinical population excluded by these criteria, and determine how OSAT guidelines incorporate evidence from these trials. METHODS We performed a systematic review to identify the eligibility criteria used across trials. We searched Medline, EMBASE, PsycINFO, Web of Science, Cochrane Library, Cochrane Clinical Trials Registry (CTR), World Health Organization International CTR Platform Search Portal, and the National Institutes of Health CTR databases from inception to January 1, 2014. To quantify the effect of trials' eligibility criteria on generalizability, we applied these criteria to data from an observational study of opioid-dependent patients (n = 394). We then accessed the Canadian, American, British, and World Health Organization (WHO) OSAT guidelines to evaluate how evidence is used in the recommendations. RESULTS Among the 60 trials identified the majority (≥50 % of trials) exclude patients with psychiatric (60 %) and physical comorbidity (51.7 %). Additionally, we found 19 trials exclude patients with current alcohol/substance-use problems (31.7 %), and 29 (48.3 %) exclude patients taking psychotropic medications. These criteria were restrictive and in some cases rendered 70 % of the observational sample ineligible. North American OSAT guidelines made strong recommendations supported by evidence with poor generalizability. National Institute of Health and Care Excellence (NICE) and WHO guidelines for opioid misuse provide a critical assessment of the literature used to inform their recommendations. CONCLUSIONS Trials assessing OSATs often exclude patients with concurrent disorders. If the excluded patients respond differently to treatment, results from these trials are likely to overestimate the true effectiveness of OSATs. North American guidelines should consider these limitations when drafting clinical recommendations.
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Affiliation(s)
- Brittany B Dennis
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.
| | - Pavel S Roshanov
- Schulich School of Medicine and Dentistry, University of Western Ontario, 4, 1465 Richmond Street, London, ON, N6G 2M1, Canada.
| | - Leen Naji
- Michael G. Degroote School of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.
| | - Monica Bawor
- McMaster Integrative Neuroscience Discovery and Study Program, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.
| | - James Paul
- Department of Anesthesia, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.
| | - Carolyn Plater
- Canadian Addiction Treatment Centres, 13291 Yonge Street, Richmond Hill, ON, L4E 4L6, Canada.
| | - Guillaume Pare
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.
| | - Andrew Worster
- Canadian Addiction Treatment Centres, 13291 Yonge Street, Richmond Hill, ON, L4E 4L6, Canada.
- Department of Medicine, Hamilton General Hospital, 237 Barton St East, Hamilton, ON, L8L 2X2, Canada.
| | - Michael Varenbut
- Canadian Addiction Treatment Centres, 13291 Yonge Street, Richmond Hill, ON, L4E 4L6, Canada.
| | - Jeff Daiter
- Canadian Addiction Treatment Centres, 13291 Yonge Street, Richmond Hill, ON, L4E 4L6, Canada.
| | - David C Marsh
- Canadian Addiction Treatment Centres, 13291 Yonge Street, Richmond Hill, ON, L4E 4L6, Canada.
- Northern Ontario School of Medicine, Ramsey Lake Road, Sudbury, ON, P0M, Canada.
| | - Dipika Desai
- Population Genomics Program, Chanchlani Research Centre, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
| | - Zainab Samaan
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.
- Population Genomics Program, Chanchlani Research Centre, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
- Peter Boris Centre for Addictions Research, St. Joseph's Healthcare Hamilton, 100 West 5th Street, Hamilton, ON, L9C 0E3, Canada.
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.
- Centre for Evaluation of Medicine, 25 Main Street West, Hamilton, ON, L8P 1H1, Canada.
- System Linked Research Unit, 175 Longwood Road, South Hamilton, L8P 0A1, Canada.
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Dayal P, Balhara YPS, Mishra AK. An open label naturalistic study of predictors of retention and compliance to naltrexone maintenance treatment among patients with opioid dependence. JOURNAL OF SUBSTANCE USE 2015. [DOI: 10.3109/14659891.2015.1021867] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Bandawar M, Kandasamy A, Chand P, Murthy P, Benegal V. Adherence to Buprenorphine Maintenance Treatment in Opioid Dependence Syndrome: A Case Control Study. Indian J Psychol Med 2015; 37:330-2. [PMID: 26664083 PMCID: PMC4649800 DOI: 10.4103/0253-7176.162951] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Opioid Use disorders are emerging as a serious public health concern in India. Opioid substitution treatment is one of the emerging forms of treatment in this population which needs more evidence to increase its availability and address prejudices towards the same. MATERIALS AND METHODS This is a case control study with retrospective design reviewing the charts of patients with opioid dependence syndrome registered between January 2005 to December 2012. Adherence to treatment was the outcome variable assessed in this study. RESULTS The odds of the Buprenorphine Maintenance Treatment (BMT) group remaining in treatment is 4.5 (P < 0.005) times more than Naltrexone Maintenance Treatment (NMT) group and 7 times (P < 0.001) more than Psychosocial intervention (PST) alone group. DISCUSSION We believe that these study findings will help in reducing the prejudice towards BMT and encourage further research in this field. CONCLUSION BMT has a better adherence rate than other treatments in opioid use disorders.
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Affiliation(s)
- Mrunal Bandawar
- Department of Clinical Neurosciences, Centre for Addiction Medicine, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - Arun Kandasamy
- Assistant Professor of Psychiatry, Centre for Addiction Medicine, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - Prabhat Chand
- Additional Professor of Psychiatry, Centre for Addiction Medicine, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - Pratima Murthy
- Professor of Psychiatry, Centre for Addiction Medicine, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - Vivek Benegal
- Professor of Psychiatry, Centre for Addiction Medicine, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
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Rawson RA, Woody G, Kresina TF, Gust S. The globalization of addiction research: capacity-building mechanisms and selected examples. Harv Rev Psychiatry 2015; 23:147-56. [PMID: 25747927 PMCID: PMC4356020 DOI: 10.1097/hrp.0000000000000067] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Over the past decade, the amount and variety of addiction research around the world has increased substantially. Researchers in Australia, Canada, United Kingdom, United States, and western Europe have significantly contributed to knowledge about addiction and its treatment. However, the nature and context of substance use disorders and the populations using drugs are far more diverse than is reflected in studies done in Western cultures. To stimulate new research from a diverse set of cultural perspectives, the National Institute on Drug Abuse (NIDA) has promoted the development of addiction research capacity and skills around the world for over 25 years. This review will describe the programs NIDA has developed to sponsor international research and research fellows and will provide some examples of the work NIDA has supported. NIDA fellowships have allowed 496 individuals from 96 countries to be trained in addiction research. The United Arab Emirates and Saudi Arabia have recently developed funding to support addiction research to study, with advice from NIDA, the substance use disorder problems that affect their societies. Examples from Malaysia, Tanzania, Brazil, Russian Federation, Ukraine, Republic of Georgia, Iceland, China, and Vietnam are used to illustrate research being conducted with NIDA support. Health services research, collaboratively funded by the U.S. National Institutes of Health and Department of State, addresses a range of addiction service development questions in low- and middle-income countries. Findings have expanded the understanding of addiction and its treatment, and are enhancing the ability of practitioners and policy makers to address substance use disorders.
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Affiliation(s)
- Richard A. Rawson
- Professor and Co-Director, UCLA Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California at Los Angeles
| | - George Woody
- Professor, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania Principal Investigator, Delaware Valley Node of Clinical Trials Network, Treatment Research Institute
| | - Thomas F. Kresina
- Division of Pharmacologic Therapies, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, Rockville, Maryland
| | - Steve Gust
- Director, International Program, National Institute on Drug Abuse, United States National Institutes of Health
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Evaluation of HIV prevention interventions for people who inject drugs in low- and middle-income countries—The current and future state of the art. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2014; 25:336-9. [DOI: 10.1016/j.drugpo.2014.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 01/11/2014] [Accepted: 01/14/2014] [Indexed: 11/18/2022]
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Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev 2014; 2014:CD002207. [PMID: 24500948 PMCID: PMC10617756 DOI: 10.1002/14651858.cd002207.pub4] [Citation(s) in RCA: 687] [Impact Index Per Article: 68.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Buprenorphine maintenance treatment has been evaluated in randomised controlled trials against placebo medication, and separately as an alternative to methadone for management of opioid dependence. OBJECTIVES To evaluate buprenorphine maintenance compared to placebo and to methadone maintenance in the management of opioid dependence, including its ability to retain people in treatment, suppress illicit drug use, reduce criminal activity, and mortality. SEARCH METHODS We searched the following databases to January 2013: Cochrane Drugs and Alcohol Review Group Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Current Contents, PsycLIT, CORK, Alcohol and Drug Council of Australia, Australian Drug Foundation, Centre for Education and Information on Drugs and Alcohol, Library of Congress, reference lists of identified studies and reviews. We sought published/unpublished randomised controlled trials (RCTs) from authors. SELECTION CRITERIA Randomised controlled trials of buprenorphine maintenance treatment versus placebo or methadone in management of opioid-dependent persons. DATA COLLECTION AND ANALYSIS We used Cochrane Collaboration methodology. MAIN RESULTS We include 31 trials (5430 participants), the quality of evidence varied from high to moderate quality.There is high quality of evidence that buprenorphine was superior to placebo medication in retention of participants in treatment at all doses examined. Specifically, buprenorphine retained participants better than placebo: at low doses (2 - 6 mg), 5 studies, 1131 participants, risk ratio (RR) 1.50; 95% confidence interval (CI) 1.19 to 1.88; at medium doses (7 - 15 mg), 4 studies, 887 participants, RR 1.74; 95% CI 1.06 to 2.87; and at high doses (≥ 16 mg), 5 studies, 1001 participants, RR 1.82; 95% CI 1.15 to 2.90. However, there is moderate quality of evidence that only high-dose buprenorphine (≥ 16 mg) was more effective than placebo in suppressing illicit opioid use measured by urinanalysis in the trials, 3 studies, 729 participants, standardised mean difference (SMD) -1.17; 95% CI -1.85 to -0.49, Notably, low-dose, (2 studies, 487 participants, SMD 0.10; 95% CI -0.80 to 1.01), and medium-dose, (2 studies, 463 participants, SMD -0.08; 95% CI -0.78 to 0.62) buprenorphine did not suppress illicit opioid use measured by urinanalysis better than placebo.There is high quality of evidence that buprenorphine in flexible doses adjusted to participant need,was less effective than methadone in retaining participants, 5 studies, 788 participants, RR 0.83; 95% CI 0.72 to 0.95. For those retained in treatment, no difference was observed in suppression of opioid use as measured by urinalysis, 8 studies, 1027 participants, SMD -0.11; 95% CI -0.23 to 0.02 or self report, 4 studies, 501 participants, SMD -0.11; 95% CI -0.28 to 0.07, with moderate quality of evidence.Consistent with the results in the flexible-dose studies, in low fixed-dose studies, methadone (≤ 40 mg) was more likely to retain participants than low-dose buprenorphine (2 - 6 mg), (3 studies, 253 participants, RR 0.67; 95% CI: 0.52 to 0.87). However, we found contrary results at medium dose and high dose: there was no difference between medium-dose buprenorphine (7 - 15 mg) and medium-dose methadone (40 - 85 mg) in retention, (7 studies, 780 participants, RR 0.87; 95% CI 0.69 to 1.10) or in suppression of illicit opioid use as measured by urines, (4 studies, 476 participants, SMD 0.25; 95% CI -0.08 to 0.58) or self report of illicit opioid use, (2 studies, 174 participants, SMD -0.82; 95% CI -1.83 to 0.19). Similarly, there was no difference between high-dose buprenorphine (≥ 16 mg) and high-dose methadone (≥ 85 mg) in retention (RR 0.79; 95% CI 0.20 to 3.16) or suppression of self-reported heroin use (SMD -0.73; 95% CI -1.08 to -0.37) (1 study, 134 participants).Few studies reported adverse events ; two studies compared adverse events statistically, finding no difference between methadone and buprenorphine, except for a single result indicating more sedation among those using methadone. AUTHORS' CONCLUSIONS Buprenorphine is an effective medication in the maintenance treatment of heroin dependence, retaining people in treatment at any dose above 2 mg, and suppressing illicit opioid use (at doses 16 mg or greater) based on placebo-controlled trials.However, compared to methadone, buprenorphine retains fewer people when doses are flexibly delivered and at low fixed doses. If fixed medium or high doses are used, buprenorphine and methadone appear no different in effectiveness (retention in treatment and suppression of illicit opioid use); however, fixed doses are rarely used in clinical practice so the flexible dose results are more relevant to patient care. Methadone is superior to buprenorphine in retaining people in treatment, and methadone equally suppresses illicit opioid use.
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Affiliation(s)
- Richard P Mattick
- University of New South WalesNational Drug and Alcohol Research CentreSydneyNew South WalesAustralia2052
| | - Courtney Breen
- University of New South WalesNational Drug and Alcohol Research CentreSydneyNew South WalesAustralia2052
| | - Jo Kimber
- University of New South WalesNational Drug and Alcohol Research CentreSydneyNew South WalesAustralia2052
| | - Marina Davoli
- Lazio Regional Health ServiceDepartment of EpidemiologyVia di Santa Costanza, 53RomeItaly00199
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Feelemyer J, Jarlais DD, Arasteh K, Abdul-Quader AS, Hagan H. Retention of participants in medication-assisted programs in low- and middle-income countries: an international systematic review. Addiction 2014; 109:20-32. [PMID: 23859638 PMCID: PMC5312702 DOI: 10.1111/add.12303] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 05/23/2013] [Accepted: 07/11/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS Medication-assisted treatment (MAT) is a key component in overdose prevention, reducing illicit opiate use and risk of blood-borne virus infection. By retaining participants in MAT programs for longer periods of time, more noticeable and permanent changes in drug use, risk behavior and quality of life can be achieved. Many studies have documented retention in MAT programs in high-income countries, using a 50% average 12-month follow-up retention rate as a marker for a successful MAT program. This study contributes to a systematic understanding of how successful programs have been in retaining participants in low- and middle-income countries (LMIC) over time. METHODS Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic literature search to identify MAT program studies that documented changes in retention over time for participants in buprenorphine and methadone programs in LMIC. Retention was measured for participants by length of follow-up, type of MAT and treatment dosage. RESULTS There were 58 MAT program studies, with 27 047 participants eligible for inclusion in the review. Overall average retention after 12 months was 54.3% [95% confidence interval (CI) = 46.2, 63.7%]. Overall average retention was moderately good for both buprenorphine (48.3%, 95% CI = 22.1, 74.6%) and methadone (56.6%, 95% CI = 45.9%, 67.3%) after 12 months of treatment. Among programs using methadone there was no statistically significant difference in average retention by dosage level, and the 10 highest and lowest dosage programs obtained similar average retention levels after 12 months. CONCLUSION Medication-assisted treatment programs in low- and middle-income countries achieve an average 50% retention rate after 12 months, with wide variation across programs but little difference between those using buprenorphine versus methadone.
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Affiliation(s)
- Jonathan Feelemyer
- The Baron Edmond de Rothschild Chemical Dependency Institute, Beth Israel Medical Center, New York, NY, USA
| | - Don Des Jarlais
- The Baron Edmond de Rothschild Chemical Dependency Institute, Beth Israel Medical Center, New York, NY, USA
| | - Kamyar Arasteh
- The Baron Edmond de Rothschild Chemical Dependency Institute, Beth Israel Medical Center, New York, NY, USA
| | - Abu S. Abdul-Quader
- Global AIDS Program, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Holly Hagan
- College of Nursing, New York University, New York, NY, USA
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Abstract
Opioid use disorder (OUD) is a major public health problem in the United States. It has resulted in devastating consequences for people with this condition, including psychosocial and legal problems, in addition to contraction of infectious diseases such as HIV and hepatitis B and C. Furthermore, this disease can cause fatalities from drug overdoses and drug-drug interactions. OUD shatters families and destroys relationships. Effective treatment is crucial in order to curtail the consequences of this condition. The objective of this article is to provide a review of the pharmacotherapies currently being used to treat OUD.
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Nucleus Accumbens Surgery for Addiction. World Neurosurg 2013; 80:S28.e9-19. [DOI: 10.1016/j.wneu.2012.10.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Revised: 07/29/2012] [Accepted: 10/02/2012] [Indexed: 02/07/2023]
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Clark N, Verster A. Double trouble-pregnancy and antagonist treatment in opioid dependence; two contentious issues needing further consideration and research. Addiction 2013; 108:253-5. [PMID: 23331880 DOI: 10.1111/j.1360-0443.2012.04096.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Nicolas Clark
- World Health Organization, WHO, Geneva, Switzerland.
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Ruger JP, Chawarski M, Mazlan M, Ng N, Schottenfeld R. Cost-effectiveness of buprenorphine and naltrexone treatments for heroin dependence in Malaysia. PLoS One 2012; 7:e50673. [PMID: 23226534 PMCID: PMC3514172 DOI: 10.1371/journal.pone.0050673] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 10/23/2012] [Indexed: 11/19/2022] Open
Abstract
Aims To aid public health policymaking, we studied the cost-effectiveness of buprenorphine, naltrexone, and placebo interventions for heroin dependence in Malaysia. Design We estimated the cost-effectiveness ratios of three treatments for heroin dependence. We used a microcosting methodology to determine fixed, variable, and societal costs of each intervention. Cost data were collected from investigators, staff, and project records on the number and type of resources used and unit costs; societal costs for participants’ time were estimated using Malaysia’s minimum wage. Costs were estimated from a provider and societal perspective and reported in 2004 US dollars. Setting Muar, Malaysia. Participants 126 patients enrolled in a randomized, double-blind, placebo-controlled clinical trial in Malaysia (2003–2005) receiving counseling and buprenorphine, naltrexone, or placebo for treatment of heroin dependence. Measurements Primary outcome measures included days in treatment, maximum consecutive days of heroin abstinence, days to first heroin use, and days to heroin relapse. Secondary outcome measures included treatment retention, injection drug use, illicit opiate use, AIDS Risk Inventory total score, and drug risk and sex risk subscores. Findings Buprenorphine was more effective and more costly than naltrexone for all primary and most secondary outcomes. Incremental cost-effectiveness ratios were below $50 for primary outcomes, mostly below $350 for secondary outcomes. Naltrexone was dominated by placebo for all secondary outcomes at almost all endpoints. Incremental treatment costs were driven mainly by medication costs, especially the price of buprenorphine. Conclusions Buprenorphine appears to be a cost-effective alternative to naltrexone that might enhance economic productivity and reduce drug use over a longer term.
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Affiliation(s)
- Jennifer Prah Ruger
- Department of Public Health, School of Medicine, Yale University, New Haven, Connecticut, United States of America.
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Abstract
Illicit use of opiates is the fastest growing substance use problem in the United States, and the main reason for seeking addiction treatment services for illicit drug use throughout the world. It is associated with significant morbidity and mortality related to human immunodeficiency virus, hepatitis C, and overdose. Treatment for opiate addiction requires long-term management. Behavioral interventions alone have extremely poor outcomes, with more than 80% of patients returning to drug use. Similarly poor results are seen with medication-assisted detoxification. This article provides a topical review of the three medications approved by the Food and Drug Administration for long-term treatment of opiate dependence: the opioid-agonist methadone, the partial opioid-agonist buprenorphine, and the opioid-antagonist naltrexone. Basic mechanisms of action and treatment outcomes are described for each medication. Results indicate that maintenance medication provides the best opportunity for patients to achieve recovery from opiate addiction. Extensive literature and systematic reviews show that maintenance treatment with either methadone or buprenorphine is associated with retention in treatment, reduction in illicit opiate use, decreased craving, and improved social function. Oral naltrexone is ineffective in treating opiate addiction, but recent studies using extended-release naltrexone injections have shown promise. Although no direct comparisons between extended-release naltrexone injections and either methadone or buprenorphine exist, indirect comparison of retention shows inferior outcome compared with methadone and buprenorphine. Further work is needed to directly compare each medication and determine individual factors that can assist in medication selection. Until such time, selection of medication should be based on informed choice following a discussion of outcomes, risks, and benefits of each medication.
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Affiliation(s)
- Gavin Bart
- Division of Addiction Medicine, Hennepin County Medical Center, Minneapolis, Minnesota 55415, USA.
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Tkacz J, Severt J, Cacciola J, Ruetsch C. Compliance with buprenorphine medication-assisted treatment and relapse to opioid use. Am J Addict 2011; 21:55-62. [PMID: 22211347 DOI: 10.1111/j.1521-0391.2011.00186.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Opioid dependence (OD), often characterized as a chronic relapsing disorder, affects millions of people worldwide. The purpose of this study was to examine the effect of compliance with buprenorphine on reducing relapse among a sample of patients in treatment for OD. Patients new to buprenorphine (N = 703) completed the Addiction Severity Index (ASI) at baseline, and at 1, 2, and 3 months postbaseline. The ASI is a semistructured interview designed to measure problem severity in seven functional areas known to be affected by alcohol and drug dependence. Compliance was defined as taking buprenorphine medication on at least 22 of the past 28 days (80%), while relapse classification was based on resumed use of opioids during the follow-up period (months 2 and 3). Relapse was regressed onto demographic indicators, baseline ASI composite scores, and compliance with buprenorphine. Noncompliant patients were over 10 times more likely to relapse than those who were compliant (exp β= 10.55; p < .001). Neither demographics nor baseline ASI composite scores were predictive of relapse (p's > .05). Compliance with medication-assisted treatment supports abstinence, essential for patient recovery. Understanding the factors that drive treatment compliance and noncompliance may assist providers in supporting patient compliance and recovery.
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Affiliation(s)
- Joseph Tkacz
- Health Analytics, LLC, 9200 Rumsey Road, Columbia, MD 21045, USA.
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Abstract
How do addiction treatment programs integrate the expectation of relapse into drug abuse treatment? This article serves as a thought piece to pose questions rather than definitive solutions. It reflects a distillation of discussions that occurred at the National Institute on Drug Abuse meeting titled "Program Response to Patient Relapse," held on July 15, 2009, along with quantitative and qualitative information about the patterns and types of discharge policies, which factors influence them, and how the culture of drug abuse treatment and the personnel interact with this issue. Some existing data on the discharging of relapsed patients are identified. A program's response to relapse is usually guided by its setting (level of care), philosophy (abstinence vs risk behavior reduction), and associated patient behavior ("benign" vs program disruptive). Key questions examined in this context include the following: Can different discharge policies impact a patient's access to treatment, and what are the implications of incorporating a medical model of addiction into discharge policies?
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Ruger JP, Chawarski M, Mazlan M, Luekens C, Ng N, Schottenfeld R. Costs of addressing heroin addiction in Malaysia and 32 comparable countries worldwide. Health Serv Res 2011; 47:865-87. [PMID: 22091732 DOI: 10.1111/j.1475-6773.2011.01335.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Develop and apply new costing methodologies to estimate costs of opioid dependence treatment in countries worldwide. DATA SOURCES/STUDY SETTING Micro-costing methodology developed and data collected during randomized controlled trial (RCT) involving 126 patients (July 2003-May 2005) in Malaysia. Gross-costing methodology developed to estimate costs of treatment replication in 32 countries with data collected from publicly available sources. STUDY DESIGN Fixed, variable, and societal cost components of Malaysian RCT micro-costed and analytical framework created and employed for gross-costing in 32 countries selected by three criteria relative to Malaysia: major heroin problem, geographic proximity, and comparable gross domestic product (GDP) per capita. PRINCIPAL FINDINGS Medication, and urine and blood testing accounted for the greatest percentage of total costs for both naltrexone (29-53 percent) and buprenorphine (33-72 percent) interventions. In 13 countries, buprenorphine treatment could be provided for under $2,000 per patient. For all countries except United Kingdom and Singapore, incremental costs per person were below $1,000 when comparing buprenorphine to naltrexone. An estimated 100 percent of opiate users in Cambodia and Lao People's Democratic Republic could be treated for $8 and $30 million, respectively. CONCLUSIONS Buprenorphine treatment can be provided at low cost in countries across the world. This study's new costing methodologies provide tools for health systems worldwide to determine the feasibility and cost of similar interventions.
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Affiliation(s)
- Jennifer Prah Ruger
- Yale School of Public Health, Health Policy and Administration, New Haven, CT 06520, USA.
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Chand P, Murthy P. Short-term outcome of take-home prescriptions for opioid dependence: a clinic-based study. JOURNAL OF SUBSTANCE USE 2011. [DOI: 10.3109/14659891.2011.615882] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Gowing L, Farrell MF, Bornemann R, Sullivan LE, Ali R. Oral substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database Syst Rev 2011:CD004145. [PMID: 21833948 DOI: 10.1002/14651858.cd004145.pub4] [Citation(s) in RCA: 165] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Injecting drug users are vulnerable to infection with Human Immunodeficiency Virus (HIV) and other blood borne viruses as a result of collective use of injecting equipment as well as sexual behaviour OBJECTIVES To assess the effect of oral substitution treatment for opioid dependent injecting drug users on risk behaviours and rates of HIV infections SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and PsycINFO to May 2011. We also searched reference lists of articles, reviews and conference abstracts SELECTION CRITERIA Studies were required to consider the incidence of risk behaviours, or the incidence of HIV infection related to substitution treatment of opioid dependence. All types of original studies were considered. Two authors independently assessed each study for inclusion DATA COLLECTION AND ANALYSIS Two authors independently extracted key information from each of the included studies. Any differences were resolved by discussion or by referral to a third author. MAIN RESULTS Thirty-eight studies, involving some 12,400 participants, were included. The majority were descriptive studies, or randomisation processes did not relate to the data extracted, and most studies were judged to be at high risk of bias. Studies consistently show that oral substitution treatment for opioid-dependent injecting drug users with methadone or buprenorphine is associated with statistically significant reductions in illicit opioid use, injecting use and sharing of injecting equipment. It is also associated with reductions in the proportion of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but has little effect on condom use. It appears that the reductions in risk behaviours related to drug use do translate into reductions in cases of HIV infection. However, because of the high risk of bias and variability in several aspects of the studies, combined totals were not calculated. AUTHORS' CONCLUSIONS Oral substitution treatment for injecting opioid users reduces drug-related behaviours with a high risk of HIV transmission, but has less effect on sex-related risk behaviours. The lack of data from randomised controlled studies limits the strength of the evidence presented in this review.
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Affiliation(s)
- Linda Gowing
- Discipline of Pharmacology, University of Adelaide, Frome Road, Adelaide, South Australia, Australia, 5005
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Levin FR, Mariani JJ, Brooks DJ, Pavlicova M, Cheng W, Nunes E. Dronabinol for the treatment of cannabis dependence: a randomized, double-blind, placebo-controlled trial. Drug Alcohol Depend 2011; 116:142-50. [PMID: 21310551 PMCID: PMC3154755 DOI: 10.1016/j.drugalcdep.2010.12.010] [Citation(s) in RCA: 138] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Revised: 12/13/2010] [Accepted: 12/14/2010] [Indexed: 02/07/2023]
Abstract
Cannabis dependence is a substantial public health problem. Behavioral treatments have shown promise, but there are no effective medications for cannabis dependence. The purpose of this study was to evaluate the safety and efficacy of dronabinol, a synthetic form of delta-9-tetrahydrocannabinol, a naturally occurring pharmacologically active component of marijuana, in treating cannabis dependence. 156 cannabis-dependent adults were enrolled in a randomized, double-blind, placebo-controlled, 12-week trial. After a 1-week placebo lead-in phase, participants were randomized to receive dronabinol 20mg twice a day or placebo. Doses were maintained until the end of week 8 and then tapered off over 2 weeks. All participants received weekly motivational enhancement and relapse prevention therapy. Marijuana use was assessed using the timeline follow back method. There was no significant difference between treatment groups in the proportion of participants who achieved 2 weeks of abstinence at the end of the maintenance phase (dronabinol: 17.7%; placebo: 15.6%). Although both groups showed a reduction in marijuana use over time, there were no differences between the groups. Treatment retention was significantly higher at the end of the maintenance phase on dronabinol (77%), compared to placebo (61%) (P=.02), and withdrawal symptoms were significantly lower on dronabinol than placebo (P=.02). This is the first trial using an agonist substitution strategy for treatment of cannabis dependence. Dronabinol showed promise, it was well-tolerated, and improved treatment retention and withdrawal symptoms. Future trials might test higher doses, combinations of dronabinol with other medications with complementary mechanisms, or with more potent behavioral interventions.
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Affiliation(s)
- Frances R. Levin
- New York State Psychiatric Institute, Division of Substance Abuse, 1051 Riverside Drive, New York, NY 10032, USA
,Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 630 West 168th Street, New York, NY 10032, USA
| | - John J. Mariani
- New York State Psychiatric Institute, Division of Substance Abuse, 1051 Riverside Drive, New York, NY 10032, USA
,Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 630 West 168th Street, New York, NY 10032, USA
| | - Daniel J. Brooks
- New York State Psychiatric Institute, Division of Substance Abuse, 1051 Riverside Drive, New York, NY 10032, USA
| | - Martina Pavlicova
- Department of Biostatistics, Columbia University, 722 West 168th Street, New York, NY 10032, USA
| | - Wendy Cheng
- New York State Psychiatric Institute, Division of Substance Abuse, 1051 Riverside Drive, New York, NY 10032, USA
,Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 630 West 168th Street, New York, NY 10032, USA
| | - Edward Nunes
- New York State Psychiatric Institute, Division of Substance Abuse, 1051 Riverside Drive, New York, NY 10032, USA
,Department of Psychiatry, College of Physicians and Surgeons of Columbia University, 630 West 168th Street, New York, NY 10032, USA
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