Are detoxification programmes effective?

Sublingual dexmedetomidine (BXCL501) reduces opioid withdrawal symptoms: findings from a multi-site, phase 1b/2, randomized, double-blind, placebo-controlled trial

Background: Like other alpha-2-adrenergic receptor agonists, dexmedetomidine may reduce the severity of opioid withdrawal but with fewer adverse cardiovascular effects.Objective: This study assessed the safety of sublingual dexmedetomidine (BXCL501) and its preliminary efficacy in treating opioid withdrawal (ClinicalTrials.gov: NCT04470050).Methods: Withdrawal was induced among individuals with physiological dependence on opioids via discontinuation of oral morphine (Days 1-5). Participants were randomized to receive placebo or active BXCL501: 30, 60, 90, 120, 180, and 240 μg twice daily (Days 6-12). Treatment-emergent adverse events (TEAEs) were the primary outcome measure. Secondary outcomes included the Clinical and Subjective Opiate Withdrawal Scales (COWS and SOWS-Gossop, respectively), and the Agitation and Calmness Evaluation Scale (ACES).Results: Of 225 participants enrolled, 90 discontinued during morphine stabilization. Post-BXCL501 randomization (Day 6) data were available from 135 participants (73% male), with 33% completing thru Day 12. In total, 36 subjects reported 1 or more TEAE. Higher doses of BXCL501 (i.e. 180 and 240 µg, twice daily) increased the frequency of: hypotension, orthostatic hypotension, and somnolence. TEAEs related to BXCL501 were mild or moderate in severity, except for one participant in the 120 µg condition whose orthostatic hypotension and bradycardia were classified as severe. Higher BXCL501 dose conditions (120, 180, and 240 µg) resulted in statistically significant reductions in COWS & SOWS scores. Mean ratings on the ACES were between 3 (mild), 4 (normal), and 5 (mild calmness), with few significant differences as a function of dose.Conclusions: These findings support the continued development of BXCL501 for the management of opioid withdrawal.

Opioid withdrawal symptoms after neurolytic splanchnic nerve block in cancer patients

PURPOSE

Few reports on opioid withdrawal (OW) due to opioid tapering in cancer patients have been published. The incidence of and risk factors for OW after neurolytic splanchnic nerve block (NSNB) are unknown. This study aimed to elucidate the incidence of and risk factors for OW among cancer patients who could have reduced opioid doses after NSNB.

METHODS

This was a multicenter, retrospective, observational study. We reviewed the medical charts of patients who underwent NSNB for intractable cancer pain at four tertiary hospitals in Yokohama City from April 2005 to October 2020. We included patients whose opioid dose was reduced by > 5 mg/day (equivalent oral morphine dose) within 14 days after NSNB. We classified the patients into two groups according to the presence or absence of OW symptoms and compared them.

RESULTS

Of the 50 patients who underwent NSNB, 24 were included in the study. OW was observed in five (20.8%) patients. Pain and opioid use duration were significantly longer in OW patients than in non-OW patients (median pain duration 689 vs. 195 days; P < 0.043 and median opioid use duration 486 vs. 136 days; P < 0.030). The opioid tapering dose was significantly larger in patients with OW than in those without OW (median opioid tapering dose 75 vs. 40 mg; P < 0.046).

CONCLUSIONS

OW was observed in 20.8% of the patients in the study. A longer pain and opioid use duration and a larger opioid tapering dose may predispose patients to OW.

Methadone, Buprenorphine, and Clonidine Attenuate Mitragynine Withdrawal in Rats

Background: Kratom or Mitragyna speciosa Korth has been widely used to relieve the severity of opioid withdrawal in natural settings. However, several studies have reported that kratom may by itself cause dependence following chronic consumption. Yet, there is currently no formal treatment for kratom dependence. Mitragynine, is the major psychoactive alkaloid in kratom. Chronic mitragynine treatment can cause addiction-like symptoms in rodent models including withdrawal behaviour. In this study we assessed whether the prescription drugs, methadone, buprenorphine and clonidine, could mitigate mitragynine withdrawal effects. In order to assess treatment safety, we also evaluated hematological, biochemical and histopathological treatment effects. Methods: We induced mitragynine withdrawal behaviour in a chronic treatment paradigm in rats. Methadone (1.0 mg/kg), buprenorphine (0.8 mg/kg) and clonidine (0.1 mg/kg) were i.p. administered over four days during mitragynine withdrawal. These treatments were stopped and withdrawal sign assessment continued. Thereafter, toxicological profiles of the treatments were evaluated in the blood and in organs. Results: Chronic mitragynine treatment caused significant withdrawal behaviour lasting at least 5 days. Methadone, buprenorphine, as well as clonidine treatments significantly attenuated these withdrawal signs. No major effects on blood or organ toxicity were observed. Conclusion: These data suggest that the already available prescription medications methadone, buprenorphine, and clonidine are capable to alleviate mitragynine withdrawal signs rats. This may suggest them as treatment options also for problematic mitragynine/kratom use in humans.

Global patterns of opioid use and dependence: harms to populations, interventions, and future action

We summarise the evidence for medicinal uses of opioids, harms related to the extramedical use of, and dependence on, these drugs, and a wide range of interventions used to address these harms. The Global Burden of Diseases, Injuries, and Risk Factors Study estimated that in 2017, 40·5 million people were dependent on opioids (95% uncertainty interval 34·3-47·9 million) and 109 500 people (105 800-113 600) died from opioid overdose. Opioid agonist treatment (OAT) can be highly effective in reducing illicit opioid use and improving multiple health and social outcomes-eg, by reducing overall mortality and key causes of death, including overdose, suicide, HIV, hepatitis C virus, and other injuries. Mathematical modelling suggests that scaling up the use of OAT and retaining people in treatment, including in prison, could avert a median of 7·7% of deaths in Kentucky, 10·7% in Kiev, and 25·9% in Tehran over 20 years (compared with no OAT), with the greater effects in Tehran and Kiev being due to reductions in HIV mortality, given the higher prevalence of HIV among people who inject drugs in those settings. Other interventions have varied evidence for effectiveness and patient acceptability, and typically affect a narrower set of outcomes than OAT does. Other effective interventions focus on preventing harm related to opioids. Despite strong evidence for the effectiveness of a range of interventions to improve the health and wellbeing of people who are dependent on opioids, coverage is low, even in high-income countries. Treatment quality might be less than desirable, and considerable harm might be caused to individuals, society, and the economy by the criminalisation of extramedical opioid use and dependence. Alternative policy frameworks are recommended that adopt an approach based on human rights and public health, do not make drug use a criminal behaviour, and seek to reduce drug-related harm at the population level.

Characteristics Associated with Nonmedical Methadone Use among People Who Inject Drugs in California

Background: Illicit, nonmedical use of opioid agonist medications such as methadone is an ongoing concern. Yet, few studies have examined nonmedical use of methadone by people who inject drugs (PWID). Objectives: This study describes the prevalence of nonmedical methadone use in a community sample of PWID and examines factors associated with recent use of nonmedical methadone. Methods: A cross-sectional sample of PWID (N = 777) was recruited using targeted sampling and interviewed in California (2011-2013). Descriptive, bivariate, and multivariate logistic regression analyses were used to determine characteristics associated with nonmedical methadone use in the last 30 days. To determine if nonmedical methadone use was associated with overdose in the last 6 months, a separate multivariate analysis was conducted. Results: Among PWID sampled, 21% reported nonmedical methadone use in the last 30 days. In multivariate logistic regression analysis, nonmedical methadone use was associated with recent methadone maintenance treatment (adjusted odds ratio [AOR] = 2.86; 95% confidence interval [CI] = 1.90, 4.30), recent nonmedical buprenorphine use (AOR = 3.12; 95% CI = 1.31, 7.47), higher injection frequency (referent <30 injections; 30-89 injections AOR = 1.89; 95% CI = 1.19, 3.02; 90-plus injections AOR = 2.43; 95% CI = 1.53, 3.87), schizophrenia diagnosis (AOR = 2.36; 95% CI = 1.36, 4.10), recent non-injection opioid prescription use (AOR = 2.97; 95% CI = 1.99, 4.43), and recent injection opioid prescription misuse (AOR = 2.13; 95% CI = 1.27, 3.59). Nonmedical methadone use was found not to be associated with nonfatal overdose (AOR = 0.77; 95% CI = 0.38, 1.56). Conclusion: Nonmedical methadone use identifies a vulnerable subpopulation among PWID, is not associated with elevated nonfatal overdose risk, and evidences a need to expand methadone treatment availability.

Opioid maintenance, weaning and detoxification techniques; where we have been, where we are now and what the future holds: an update

In 2017, the US Department of Health and Human Services declared a public health emergency on the opioid crisis. On average, 115 Americans die each day from an opioid overdose. The scope and breadth of this problem is continually evolving. In 2010, there was a shift in causes primarily due to the use of heroin, and currently the latest shift in opioid-related deaths involves a variety of synthetic opioids, particularly illicitly manufactured fentanyl. As the medical, sociological and political environments have drastically changed, especially in the USA, over the last 6 years with regard to opioid use and misuse, an updated review of the literature was necessary.

Correlates of specialty substance use treatment among adults with opioid use disorders

AIMS

To identify factors associated with the receipt of specialty substance use treatment among adults with opioid use disorders (OUD).

DESIGN

Cross-sectional study based on 2010-2014 National Surveys on Drug Use and Health (NSDUH).

SETTING AND PARTICIPANTS

Adults with a past-year OUD (n = 2488). The sample is representative of non-institutionalized US adults.

MEASUREMENTS

Past-year OUD was determined using DSM-IV criteria. Past-year specialty substance use treatment was defined as receiving treatment for drug use at any of the following locations: rehabilitation facilities, hospitals (inpatient only), outpatient mental health centers, private doctors' offices, or methadone clinics. Multivariable logistic regression models were used to measure the independent association between potential correlates and specialty substance use treatment receipt.

FINDINGS

Of adults with an OUD, 8.3% received past-year specialty substance use treatment. In a fully adjusted logistic regression model, the following factors were associated with increased odds of receiving specialty substance use treatment: ≥ 35 years old (adjusted Odds Ratio (aOR) = 2.55, 95% Confidence Interval (CI) = 1.04-6.26); unemployment (aOR = 1.92, 95% CI = 1.02-3.61); not in the labor force (aOR = 2.16, 95% CI = 1.15-4.06); never been married (aOR = 2.14, 95% CI = 1.04-4.39); arrested in past 12 months (aOR = 4.43, 95% CI = 2.45-7.99); opioid dependence (aOR = 3.82, 95% CI = 2.06-7.10); alcohol use disorder (aOR = 2.44, 95% CI = 1.44-4.11); and another drug use disorder (aOR = 3.22, 95% CI = 1.95-5.32). Living in a non-metropolitan county (aOR = 0.29, 95% CI = 0.12-0.68) and fair/poor health (aOR = 0.38, 95% CI = 0.17-0.86) were associated with decreased odds of receiving specialty substance use treatment.

CONCLUSIONS

These findings suggest a need for the following efforts: strategies to increase individuals' recognition of their need for OUD treatment, expansion of insurance coverage for substance use treatment, expansion of earlier intervention services, adoption of a chronic care approach to substance use treatment, and an expansion of treatment capacity for rural communities.

Efficacy of buprenorphine and clonidine in opioid detoxification: A hospital- based study

BACKGROUND

The need for effective and accepted method for opioid detoxification is ever increasing. Sublingual buprenorphine and oral clonidine have been effective in opioid detoxification. As often, there is a great variation in the dosage of buprenorphine and clonidine prescribed by the clinicians; hence, there is a felt need to find an effective dosage for a favorable outcome of opioid detoxification.

OBJECTIVE

The objective of this study was to compare the effectiveness of different doses of sublingual buprenorphine and clonidine in opioid detoxification.

MATERIALS AND METHODS

A total of 100 patients with the diagnosis of opioid dependence as per the international classification of diseases-10 criteria were recruited for this study. Participants were assigned randomly into four groups - low-dose clonidine, high-dose clonidine, low-dose sublingual buprenorphine, and high sublingual dose buprenorphine using a computer-generated random number table, resulting in 25, 26, 23, and 26 patients in each group, respectively.

RESULTS

The four groups had comparable scores on all the items of "stages of change readiness and treatment eagerness scale" for the assessment of motivation at baseline. Progressive decrease in withdrawal score was seen in all the groups on "clinical opiate withdrawal scale" and "subjective opiate withdrawal scale."

CONCLUSION

From the current study, we can infer that both low and high doses of buprenorphine and clonidine are comparable regarding controlling withdrawal.

A Crisis Within a Crisis: The Extended Closure of an Opioid Treatment Program After Hurricane Sandy

Disruptions in opioid treatment programs (OTPs) are common after major disasters. Highly regulated OTPs confront challenges when responding to extended closures following disaster. Following Hurricane Sandy in 2012, an OTP located at the Manhattan Veteran Affairs Medical Center (VAMC) closed for 5 months. Semistructured interviews were conducted with clinicians and administrators who participated in the evacuation of the Manhattan VAMC, including the co-located OTP program. The Manhattan OTP preemptively dispensed emergency take-home methadone doses. Following closure, emergency guest-dosing arrangements were made for approximately 100 Veterans with Veterans Affairs (VA) and non-VA OTPs throughout New York City. Fortuitously, a retired VA OTP at another facility was reopened and accredited expeditiously. OTPs must improve contingencies for emergency response. However, disruptions in methadone delivery and threats to patient safety are likely to continue until agencies with oversight authority of OTPs describe specifications for emergency alternate care sites during long-term disaster recovery.

Withdrawal-associated injury site pain (WISP): a descriptive case series of an opioid cessation phenomenon

Supplemental Digital Content is Available in the Text.

This descriptive case series among adults documents that pain can return temporarily at healed, previously pain-free injury sites during acute opioid withdrawal.

Withdrawal pain can be a barrier to opioid cessation. Yet, little is known about old injury site pain in this context. We conducted an exploratory mixed-methods descriptive case series using a web-based survey and in-person interviews with adults recruited from pain and addiction treatment and research settings. We included individuals who self-reported a past significant injury that was healed and pain-free before the initiation of opioids, which then became temporarily painful upon opioid cessation—a phenomenon we have named withdrawal-associated injury site pain (WISP). Screening identified WISP in 47 people, of whom 34 (72%) completed the descriptive survey, including 21 who completed qualitative interviews. Recalled pain severity scores for WISP were typically high (median: 8/10; interquartile range [IQR]: 2), emotionally and physically aversive, and took approximately 2 weeks to resolve (median: 14; IQR: 24 days). Withdrawal-associated injury site pain intensity was typically slightly less than participants' original injury pain (median: 10/10; IQR: 3), and more painful than other generalized withdrawal symptoms which also lasted approximately 2 weeks (median: 13; IQR: 25 days). Fifteen surveyed participants (44%) reported returning to opioid use because of WISP in the past. Participants developed theories about the etiology of WISP, including that the pain is the brain's way of communicating a desire for opioids. This research represents the first known documentation that previously healed, and pain-free injury sites can temporarily become painful again during opioid withdrawal, an experience which may be a barrier to opioid cessation, and a contributor to opioid reinitiation.

Opioid antagonists with minimal sedation for opioid withdrawal

BACKGROUND

Managed withdrawal is a necessary step prior to drug-free treatment or as the endpoint of long-term substitution treatment.

OBJECTIVES

To assess the effects of opioid antagonists plus minimal sedation for opioid withdrawal. Comparators were placebo as well as more established approaches to detoxification, such as tapered doses of methadone, adrenergic agonists, buprenorphine and symptomatic medications.

SEARCH METHODS

We updated our searches of the following databases to December 2016: CENTRAL, MEDLINE, Embase, PsycINFO and Web of Science. We also searched two trials registers and checked the reference lists of included studies for further references to relevant studies.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled clinical trials along with prospective controlled cohort studies comparing opioid antagonists plus minimal sedation versus other approaches or different opioid antagonist regimens for withdrawal in opioid-dependent participants.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Ten studies (6 randomised controlled trials and 4 prospective cohort studies, involving 955 participants) met the inclusion criteria for the review. We considered 7 of the 10 studies to be at high risk of bias in at least one of the domains we assessed.Nine studies compared an opioid antagonist-adrenergic agonist combination versus a treatment regimen based primarily on an alpha2-adrenergic agonist (clonidine or lofexidine). Other comparisons (placebo, tapered doses of methadone, buprenorphine) made by included studies were too diverse for any meaningful analysis. This review therefore focuses on the nine studies comparing an opioid antagonist (naltrexone or naloxone) plus clonidine or lofexidine versus treatment primarily based on clonidine or lofexidine.Five studies took place in an inpatient setting, two studies were in outpatients with day care, two used day care only for the first day of opioid antagonist administration, and one study described the setting as outpatient without indicating the level of care provided.The included studies were heterogeneous in terms of the type of opioid antagonist treatment regimen, the comparator, the outcome measures assessed, and the means of assessing outcomes. As a result, the validity of any estimates of overall effect is doubtful, therefore we did not calculate pooled results for any of the analyses.The quality of the evidence for treatment with an opioid antagonist-adrenergic agonist combination versus an alpha2-adrenergic agonist is very low. Two studies reported data on peak withdrawal severity, and four studies reported data on the average severity over the period of withdrawal. Peak withdrawal induced by opioid antagonists in combination with an adrenergic agonist appears to be more severe than withdrawal managed with clonidine or lofexidine alone, but the average severity over the withdrawal period is less. In some situations antagonist-induced withdrawal may be associated with significantly higher rates of treatment completion compared to withdrawal managed with adrenergic agonists. However, this result was not consistent across studies, and the extent of any benefit is highly uncertain.We could not extract any data on the occurrence of adverse events, but two studies reported delirium or confusion following the first dose of naltrexone. Delirium may be more likely with higher initial doses and with naltrexone rather than naloxone (which has a shorter half-life), but we could not confirm this from the available evidence.Insufficient data were available to make any conclusions on the best duration of treatment.

AUTHORS' CONCLUSIONS

Using opioid antagonists plus alpha2-adrenergic agonists is a feasible approach for managing opioid withdrawal. However, it is unclear whether this approach reduces the duration of withdrawal or facilitates transfer to naltrexone treatment to a greater extent than withdrawal managed primarily with an adrenergic agonist.A high level of monitoring and support is desirable for several hours following administration of opioid antagonists because of the possibility of vomiting, diarrhoea and delirium.Using opioid antagonists to induce and accelerate opioid withdrawal is not currently an active area of research or clinical practice, and the research community should give greater priority to investigating approaches, such as those based on buprenorphine, that facilitate the transition to sustained-release preparations of naltrexone.

Buprenorphine for managing opioid withdrawal

BACKGROUND

Managed withdrawal is a necessary step prior to drug-free treatment or as the endpoint of substitution treatment.

OBJECTIVES

To assess the effects of buprenorphine versus tapered doses of methadone, alpha2-adrenergic agonists, symptomatic medications or placebo, or different buprenorphine regimens for managing opioid withdrawal, in terms of the intensity of the withdrawal syndrome experienced, duration and completion of treatment, and adverse effects.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 11, 2016), MEDLINE (1946 to December week 1, 2016), Embase (to 22 December 2016), PsycINFO (1806 to December week 3, 2016), and the Web of Science (to 22 December 2016) and handsearched the reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials of interventions using buprenorphine to modify the signs and symptoms of withdrawal in participants who were primarily opioid dependent. Comparison interventions involved reducing doses of methadone, alpha2-adrenergic agonists (clonidine or lofexidine), symptomatic medications or placebo, and different buprenorphine-based regimens.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 27 studies involving 3048 participants. The main comparators were clonidine or lofexidine (14 studies). Six studies compared buprenorphine versus methadone, and seven compared different rates of buprenorphine dose reduction. We assessed 12 studies as being at high risk of bias in at least one of seven domains of methodological quality. Six of these studies compared buprenorphine with clonidine or lofexidine and two with methadone; the other four studies compared different rates of buprenorphine dose reduction.For the comparison of buprenorphine and methadone in tapered doses, meta-analysis was not possible for the outcomes of intensity of withdrawal or adverse effects. However, information reported by the individual studies was suggestive of buprenorphine and methadone having similar capacity to ameliorate opioid withdrawal, without clinically significant adverse effects. The meta-analyses that were possible support a conclusion of no difference between buprenorphine and methadone in terms of average treatment duration (mean difference (MD) 1.30 days, 95% confidence interval (CI) -8.11 to 10.72; N = 82; studies = 2; low quality) or treatment completion rates (risk ratio (RR) 1.04, 95% CI 0.91 to 1.20; N = 457; studies = 5; moderate quality).Relative to clonidine or lofexidine, buprenorphine was associated with a lower average withdrawal score (indicating less severe withdrawal) during the treatment episode, with an effect size that is considered to be small to moderate (standardised mean difference (SMD) -0.43, 95% CI -0.58 to -0.28; N = 902; studies = 7; moderate quality). Patients receiving buprenorphine stayed in treatment for longer, with an effect size that is considered to be large (SMD 0.92, 95% CI 0.57 to 1.27; N = 558; studies = 5; moderate quality) and were more likely to complete withdrawal treatment (RR 1.59, 95% CI 1.23 to 2.06; N = 1264; studies = 12; moderate quality). At the same time there was no significant difference in the incidence of adverse effects, but dropout due to adverse effects may be more likely with clonidine (RR 0.20, 95% CI 0.04 to 1.15; N = 134; studies = 3; low quality). The difference in treatment completion rates translates to a number needed to treat for an additional beneficial outcome of 4 (95% CI 3 to 6), indicating that for every four people treated with buprenorphine, we can expect that one additional person will complete treatment than with clonidine or lofexidine.For studies comparing different rates of reduction of the buprenorphine dose, meta-analysis was possible only for treatment completion, with separate analyses for inpatient and outpatient settings. The results were diverse, and we assessed the quality of evidence as being very low. It remains very uncertain what effect the rate of dose taper has on treatment outcome.

AUTHORS' CONCLUSIONS

Buprenorphine is more effective than clonidine or lofexidine for managing opioid withdrawal in terms of severity of withdrawal, duration of withdrawal treatment, and the likelihood of treatment completion.Buprenorphine and methadone appear to be equally effective, but data are limited. It remains possible that the pattern of withdrawal experienced may differ and that withdrawal symptoms may resolve more quickly with buprenorphine.It is not possible to draw any conclusions from the available evidence on the relative effectiveness of different rates of tapering the buprenorphine dose. The divergent findings of studies included in this review suggest that there may be multiple factors affecting the response to the rate of dose taper. One such factor could be whether or not the initial treatment plan includes a transition to subsequent relapse prevention treatment with naltrexone. Indeed, the use of buprenorphine to support transition to naltrexone treatment is an aspect worthy of further research.Most participants in the studies included in this review were male. None of the studies reported outcomes on the basis of sex, preventing any exploration of differences related to this variable. Consideration of sex as a factor influencing response to withdrawal treatment would be relevant research for selecting the most appropriate type of intervention for each individual.

Institutional Dilemmas

Because high drop-out rates have long plagued drug treatment programs, researchers have spent considerable energy searching for risk factors to predict dropout, with only limited success. In this ethnographic study of a long-term residential treatment program, I argue that failure in residential treatment does not stem from high-risk individual-level characteristics, but from the inherent difficulties of making a turning point in drug treatment. Drug users enter treatment at unstable points in their life course, when they are least equipped to handle stressful experiences. Yet entrance into treatment introduces new stressors, particularly the adaptation to a new, demanding environment. I argue that the very characteristics of residential treatment that enable a drug addict to desist—surveillance, routine activities, rules, and confinement—also make her want to escape. This article elaborates on institutional dilemmas that make treatment difficult and unpredictable, presenting an alternative to the risk factors approach to dropout.

Patients' Perspectives on Tapering of Chronic Opioid Therapy: A Qualitative Study

OBJECTIVE : There is inadequate evidence of long-term benefit and growing evidence of the risks of chronic opioid therapy (COT). Opioid dose reduction, or opioid tapering, may reduce these risks but may also worsen pain and quality of life. Our objective was to explore patients' perspectives on opioid tapering. DESIGN : Qualitative study using in-person, semistructured interviews. SETTING AND PATIENTS : English-speaking, adult primary care patients (N = 24) in three Colorado health care systems. METHODS : Interviews were audio recorded, transcribed, and analyzed in ATLAS.ti. We used a team-based, mixed inductive and deductive approach guided by the Health Belief Model. We iteratively refined emergent themes with input from a multidisciplinary team. RESULTS : Participants had a mean age of 52 years old, were 46% male and 79% white. Six participants (25%) were on COT and not tapering, 12 (50%) were currently tapering COT, and 6 (25%) had discontinued COT. Emergent themes were organized in four domains: risks, barriers, facilitators, and benefits. Patients perceived a low risk of overdose and prioritized the more immediate risk of increased pain with opioid tapering. Barriers included a perceived lack of effectiveness of nonopioid options and fear of opioid withdrawal. Among patients with opioid tapering experience, social support and a trusted health care provider facilitated opioid tapering. These patients endorsed improved quality of life following tapering. CONCLUSIONS : Efforts to support opioid tapering should elicit patients' perceived barriers and seek to build on relationships with family, peers, and providers to facilitate tapering. Future work should identify patient-centered, feasible strategies to support tapering of COT.

Alpha₂-adrenergic agonists for the management of opioid withdrawal

BACKGROUND

Withdrawal is a necessary step prior to drug-free treatment or as the endpoint of long-term substitution treatment.

OBJECTIVES

To assess the effectiveness of interventions involving the use of alpha2-adrenergic agonists compared with placebo, reducing doses of methadone, symptomatic medications, or an alpha2-adrenergic agonist regimen different to the experimental intervention, for the management of the acute phase of opioid withdrawal. Outcomes included the withdrawal syndrome experienced, duration of treatment, occurrence of adverse effects, and completion of treatment.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1946 to November week 2, 2015), EMBASE (January 1985 to November week 2, 2015), PsycINFO (1806 to November week 2, 2015), Web of Science, and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials comparing alpha2-adrenergic agonists (clonidine, lofexidine, guanfacine, tizanidine) with reducing doses of methadone, symptomatic medications or placebo, or comparing different alpha2-adrenergic agonists to modify the signs and symptoms of withdrawal in participants who were opioid dependent.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included 26 randomised controlled trials involving 1728 participants. Six studies compared an alpha2-adrenergic agonist with placebo, 12 with reducing doses of methadone, four with symptomatic medications, and five compared different alpha2-adrenergic agonists. We assessed 10 studies as having a high risk of bias in at least one of the methodological domains that were considered.We found moderate-quality evidence that alpha2-adrenergic agonists were more effective than placebo in ameliorating withdrawal in terms of the likelihood of severe withdrawal (risk ratio (RR) 0.32, 95% confidence interval (CI) 0.18 to 0.57; 3 studies; 148 participants). We found moderate-quality evidence that completion of treatment was significantly more likely with alpha2-adrenergic agonists compared with placebo (RR 1.95, 95% CI 1.34 to 2.84; 3 studies; 148 participants).Peak withdrawal severity may be greater with alpha2-adrenergic agonists than with reducing doses of methadone, as measured by the likelihood of severe withdrawal (RR 1.18, 95% CI 0.81 to 1.73; 5 studies; 340 participants; low quality), and peak withdrawal score (standardised mean difference (SMD) 0.22, 95% CI -0.02 to 0.46; 2 studies; 263 participants; moderate quality), but these differences were not significant and there is no significant difference in severity when considered over the entire duration of the withdrawal episode (SMD 0.13, 95% CI -0.24 to 0.49; 3 studies; 119 participants; moderate quality). The signs and symptoms of withdrawal occurred and resolved earlier with alpha2-adrenergic agonists. The duration of treatment was significantly longer with reducing doses of methadone (SMD -1.07, 95% CI -1.31 to -0.83; 3 studies; 310 participants; low quality). Hypotensive or other adverse effects were significantly more likely with alpha2-adrenergic agonists (RR 1.92, 95% CI 1.19 to 3.10; 6 studies; 464 participants; low quality), but there was no significant difference in rates of completion of withdrawal treatment (RR 0.85, 95% CI 0.69 to 1.05; 9 studies; 659 participants; low quality).There were insufficient data for quantitative comparison of different alpha2-adrenergic agonists. Available data suggest that lofexidine does not reduce blood pressure to the same extent as clonidine, but is otherwise similar to clonidine.

AUTHORS' CONCLUSIONS

Clonidine and lofexidine are more effective than placebo for the management of withdrawal from heroin or methadone. We detected no significant difference in efficacy between treatment regimens based on clonidine or lofexidine and those based on reducing doses of methadone over a period of around 10 days, but methadone was associated with fewer adverse effects than clonidine, and lofexidine has a better safety profile than clonidine.

Alcohol use disorders

Alcohol use disorders are common in developed countries, where alcohol is cheap, readily available, and heavily promoted. Common, mild disorders often remit in young adulthood, but more severe disorders can become chronic and need long-term medical and psychological management. Doctors are uniquely placed to opportunistically assess and manage alcohol use disorders, but in practice diagnosis and treatment are often delayed. Brief behavioural intervention is effective in primary care for hazardous drinkers and individuals with mild disorders. Brief interventions could also encourage early entry to treatment for people with more-severe illness who are underdiagnosed and undertreated. Sustained abstinence is the optimum outcome for severe disorder. The stigma that discourages treatment seeking needs to be reduced, and pragmatic approaches adopted for patients who initially reject abstinence as a goal. To engage people in one or more psychological and pharmacological treatments of equivalent effectiveness is more important than to advocate a specific treatment. A key research priority is to improve the diagnosis and treatment of most affected people who have comorbid mental and other drug use disorders.

Searching for evidence of genetic mediation of opioid withdrawal by opioid receptor gene polymorphisms

BACKGROUND

Previous research has identified many genetic polymorphisms that appear to mediate the effects of opioid drugs. However, the relationship between genetic polymorphisms and the severity of opioid withdrawal has not yet been characterized.

METHODS

Data were collected from 48 daily heroin users who previously completed a standardized abstinence-induced or naloxone-precipitated withdrawal procedure to assess opioid dependence. The total withdrawal severity score (based on the COWS) from this procedure was correlated with genotype information for variants of OPRM1 (rs1799971; rs6848893), OPRD1 (rs10753331; rs2234918; rs581111; rs678849; rs1042114), and OPRK1 (rs6473797; rs963549). Genotype and other participant variables (age, race, sex, duration of drug use, concomitant drug use, route of opioid use) were used as predictors.

RESULTS

Of these variables, those individually correlated with a p < .2 were entered into a multivariate regression in order to identify the most predictive model. Three polymorphisms were significantly associated with severity of abstinence-induced withdrawal (n = 19) in the bivariate analysis (R): OPRM1 rs6848893 (.45), OPRD1 rs10753331 (.03), and rs678849 (.08), but only the OPRM1 rs6848893 was retained in the multivariate model (p < .001). For participants who underwent naloxone-precipitated withdrawal (n = 29) only OPRK1 rs6473797 (-.23) was significant in the bivariate analysis, though not retained in the final model.

CONCLUSIONS

These data provide evidence for genetic modulation of opioid withdrawal severity, and suggest there may be qualitative differences between withdrawal resulting from abstinence and antagonist-precipitated withdrawal.

SCIENTIFIC SIGNIFICANCE

This study demonstrates the importance and feasibility of incorporating genetic information into clinical addiction research.

Preferences for Aftercare Among Persons Seeking Short-Term Opioid Detoxification

Without aftercare treatment, the period following discharge from short-term inpatient detoxification for opioid dependence presents a high risk of relapse. Yet the role of patient preference in treatment selection is rarely discussed in the substance-abuse literature. We surveyed 485 persons initiating inpatient opioid detoxification who were predominantly male (71.3%) and had detoxed in the past (73.2%). When asked to choose the one treatment that would work best for them after discharge, 43% of participants selected medication-assisted treatment (MAT), 29% preferred residential, 12% selected drug-free counseling, 12% NA/AA meetings only, and 4% preferred no additional treatment. Residential treatment preference was significantly associated with homelessness, having been in a detox program within the past year, and having pending legal problems, indicating that there is a distinct profile of detox patients who prefer residential treatment despite its limited availability. Detox program staff should work with patients to understand reasons for treatment preferences to optimize aftercare services.

Tapering Long-term Opioid Therapy in Chronic Noncancer Pain: Evidence and Recommendations for Everyday Practice

Increasing concern about the risks and limited evidence supporting the therapeutic benefit of long-term opioid therapy for chronic noncancer pain are leading prescribers to consider discontinuing the use of opioids. In addition to overt addiction or diversion, the presence of adverse effects, diminishing analgesia, reduced function and quality of life, or the absence of progress toward functional goals can justify an attempt at weaning patients from long-term opioid therapy. However, discontinuing opioid therapy is often hindered by patients' psychiatric comorbidities and poor coping skills, as well as the lack of formal guidelines for the prescribers. The aim of this article is to review the existing literature and formulate recommendations for practitioners aiming to discontinue long-term opioid therapy. Specifically, this review aims to answer the following questions: What is an optimal opioid tapering regimen? How can the risks involved in a taper be managed? What are the alternatives to an opioid taper? A PubMed literature search was conducted using the keywords chronic pain combined with opioid withdrawal, taper, wean and detoxification. Six hundred ninety-five documents were identified and screened; 117 were deemed directly relevant and are included. On the base of this literature review, this article proposes evidence-based recommendations and expert-based suggestions for clinical practice. Furthermore, areas of lack of evidence are identified, providing opportunities for further research.

Opioid and GABAB receptors differentially couple to an adenylyl cyclase/protein kinase A downstream effector after chronic morphine treatment

Opioids are intensely addictive, and cessation of their chronic use is associated with a highly aversive withdrawal syndrome. A cellular hallmark of withdrawal is an opioid sensitive protein kinase A-dependent increase in GABA transporter-1 (GAT-1) currents in periaqueductal gray (PAG) neurons. Elevated GAT-1 activity directly increases GABAergic neuronal excitability and synaptic GABA release, which will enhance GABAergic inhibition of PAG output neurons. This reduced activity of PAG output neurons to several brain regions, including the hypothalamus and medulla, contributes to many of the PAG-mediated signs of opioid withdrawal. The GABA_B receptor agonist baclofen reduces some of the PAG mediated signs of opioid withdrawal. Like the opioid receptors the GABA_B receptor is a G_i/G_o coupled G-protein coupled receptor. This suggests it could be modulating GAT-1 activity in PAG neurons through its inhibition of the adenylyl cyclase/protein kinase A pathway. Opioid modulation of the GAT-1 activity can be detected by changes in the reversal potential of opioid membrane currents. We found that when opioids are reducing the GAT-1 cation conductance and increasing the GIRK conductance the opioid agonist reversal potential is much more negative than E_k. Using this approach for GABA_B receptors we show that the GABA_B receptor agonist, baclofen, does not couple to inhibition of GAT-1 currents during opioid withdrawal. It is possible this differential signaling of the two G_i/G_o coupled G-protein coupled receptors is due to the strong compartmentalization of the GABA_B receptor that does not favor signaling to the adenylyl cyclase/protein kinase A/GAT-1 pathway. This highlights the importance of studying the effects of G-protein coupled receptors in native tissue with endogenous G-protein coupled receptors and the full complement of relevant proteins and signaling molecules. This study suggests that baclofen reduces opioid withdrawal symptoms through a non-GAT-1 effector.

Buprenorphine detoxification treatment for heroin dependence: a preliminary experience in an outpatient setting

OBJECTIVES

The aim of the study was to evaluate buprenorphine as a detoxification agent for heroin dependence in an outpatient setting. Specifically we sought to establish the rate of completion of detoxification and retention in treatment, the duration of successful detoxification and dose requirements.

METHODS

The study was an open prospective evaluation of routinely collected clinical data on the first 60 consecutive heroin dependent patients who underwent buprenorphine detoxification. A flexible dosing regime was adopted with the dose of buprenorphine being adjusted daily against the previous day's withdrawal symptoms.

RESULTS

The majority of patients (40 (67%)) completed detoxification. The median duration of treatment for completers was 17 days (range 9-30 days) with 90% of detoxification episodes completed within 21 days. Patients were commenced on initial median dose of 4mg buprenorphine (range 2mg-6mg) and the median stabilisation dose for the sample was 10mg daily (range 6mg-14mg). The median final dosage of buprenorphine required by patients retained in treatment was 1.2mg (range 0.4mg-2mg). We found older patient age to be a significant predictor of treatment completion.

CONCLUSIONS

Buprenorphine was an acceptable and a feasible outpatient detoxification treatment option for heroin dependent patients. Based on the study findings we propose a standard 21-day fixed-dose detoxification schedule.

Opioid maintenance, weaning and detoxification techniques: where we have been, where we are now and what the future holds

SUMMARY Medically supervised opioid withdrawal is a complex and constantly evolving exercise in multimodal therapy that draws from the expertise of a variety of clinical specialties. Acute substitution and weaning has been performed utilizing opioid agonists, partial agonists (e.g., buprenorphine), mixed agonist/antagonists (e.g., Suboxone®), and α2 adrenergic agonists. While thousands of patients are being treated with these 'classic' opioid-withdrawal techniques, traditional treatment approaches are being challenged by the emergence of innovative techniques based on an understanding of the neurochemistry of addiction. Pharmacotherapy with controlled withdrawal is currently the most reliable method of opioid detoxification, but, as translational medicine continues to advance and genomic markers for opioid sensitivity and dependence are identified, the future shows great potential for growth and change.

Detoxification treatments for opiate dependent adolescents

BACKGROUND

The scientific literature examining effective treatments for opioid dependent adults clearly indicates that pharmacotherapy is a necessary and acceptable component of effective treatments for opioid dependence. Nevertheless, no studies have been published that systematically assess the effectiveness of the pharmacological detoxification among adolescents.

OBJECTIVES

To assess the effectiveness of any detoxification treatment alone or in combination with psychosocial intervention compared with no intervention, other pharmacological intervention or psychosocial interventions on completion of treatment, reducing the use of substances and improving health and social status.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (2014, Issue 1), PubMed (January 1966 to January 2014), EMBASE (January 1980 to January 2014), CINHAL (January 1982 to January 2014), Web of Science (1991-January 2014) and reference lists of articles.

SELECTION CRITERIA

Randomised controlled clinical trials comparing any pharmacological interventions alone or associated with psychosocial intervention aimed at detoxification with no intervention, placebo, other pharmacological intervention or psychosocial intervention in adolescents (13 to 18 years).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by The Cochrane Collaboration

MAIN RESULTS

Two trials involving 190 participants were included. One trial compared buprenorphine with clonidine for detoxification. No difference was found for drop out: risk ratio (RR) 0.45 (95% confidence interval (CI): 0.20 to 1.04) and acceptability of treatment: withdrawal score mean difference (MD): 3.97 (95% CI -1.38 to 9.32). More participants in the buprenorphine group initiated naltrexone treatment: RR 11.00 (95% CI 1.58 to 76.55), quality of evidence moderate.The other trial compared maintenance treatment versus detoxification treatment: buprenorphine-naloxone maintenance versus buprenorphine detoxification. For drop out the results were in favour of maintenance treatment: RR 2.67 (95% CI 1.85, 3.86), as well as for results at follow-up RR 1.36 [95% CI 1.05to 1.76); no differences for use of opiate, quality of evidence low.

AUTHORS' CONCLUSIONS

It is difficult to draw conclusions on the basis of two trials with few participants. Furthermore, the two studies included did not consider the efficacy of methadone that is still the most frequent drug utilised for the treatment of opioid withdrawal. One possible reason for the lack of evidence could be the difficulty in conducting trials with young people due to practical and ethical reasons.

Alpha2-adrenergic agonists for the management of opioid withdrawal

BACKGROUND

Withdrawal is a necessary step prior to drug-free treatment or as the endpoint of long-term substitution treatment.

OBJECTIVES

To assess the effectiveness of interventions involving the use of alpha2-adrenergic agonists compared with placebo, reducing doses of methadone, symptomatic medications or with comparison of different alpha2-adrenergic agonists, for the management of the acute phase of opioid withdrawal. Outcomes included the intensity of signs and symptoms and overall withdrawal syndrome experienced, duration of treatment, occurrence of adverse effects and completion of treatment.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (Issue 7, 2013), MEDLINE (1946 to July week 4, 2013), EMBASE (January 1985 to August week 1, 2013), PsycINFO (1806 to July week 5, 2013) and reference lists of articles. We also contacted manufacturers in the field.

SELECTION CRITERIA

Randomised controlled trials comparing alpha2-adrenergic agonists (clonidine, lofexidine, guanfacine, tizanidine) with reducing doses of methadone, symptomatic medications or placebo, or comparing different alpha2-adrenergic agonists to modify the signs and symptoms of withdrawal in participants who were opioid dependent.

DATA COLLECTION AND ANALYSIS

One review author assessed studies for inclusion and undertook data extraction. All review authors decided on inclusion and confirmed the overall process.

MAIN RESULTS

We included 25 randomised controlled trials, involving 1668 participants. Five studies compared a treatment regimen based on an alpha2-adrenergic agonist with placebo, 12 with a regimen based on reducing doses of methadone, four with symptomatic medications and five compared different alpha2-adrenergic agonists.Alpha2-adrenergic agonists were more effective than placebo in ameliorating withdrawal in terms of the likelihood of severe withdrawal (risk ratio (RR) 0.32, 95% confidence interval (CI) 0.18 to 0.57, 3 studies, 148 participants). Completion of treatment was significantly more likely with alpha2-adrenergic agonists compared with placebo (RR 1.95, 95% CI 1.34 to 2.84, 3 studies, 148 participants).Alpha2-adrenergic agonists were somewhat less effective than reducing doses of methadone in ameliorating withdrawal symptoms, as measured by the likelihood of severe withdrawal (RR 1.18, 95% CI 0.81 to 1.73, 5 studies, 340 participants), peak withdrawal score (standardised mean difference (SMD) 0.22, 95% CI -0.02 to 0.46, 2 studies, 263 participants) and overall withdrawal severity (SMD 0.13, 95% CI -0.24 to 0.49, 3 studies, 119 participants). These differences were not statistically significant. The signs and symptoms of withdrawal occurred and resolved earlier with alpha2-adrenergic agonists. The duration of treatment was significantly longer with reducing doses of methadone (SMD -1.07, 95% CI -1.31 to -0.83, 3 studies, 310 participants). Hypotensive or other adverse effects were significantly more likely with alpha2-adrenergic agonists (RR 1.92, 95% CI 1.19 to 3.10, 6 studies, 464 participants) but there was no significant difference in rates of completion of withdrawal treatment (RR 0.85, 95% CI 0.69 to 1.05, 9 studies, 659 participants).There were insufficient data for quantitative comparison of different alpha2-adrenergic agonists. Available data suggest that lofexidine does not reduce blood pressure to the same extent as clonidine, but is otherwise similar to clonidine.

AUTHORS' CONCLUSIONS

Clonidine and lofexidine are more effective than placebo for the management of withdrawal from heroin or methadone. No significant difference in efficacy was detected for treatment regimens based on clonidine or lofexidine, and those based on reducing doses of methadone over a period of around 10 days but methadone is associated with fewer adverse effects than clonidine, and lofexidine has a better safety profile than clonidine.

Feasibility of ambulatory withdrawal management delivered in a NSW drug health service and correlates of completion

OBJECTIVE

The aim of the present study was to assess short-term ambulatory withdrawal management (AWM) outcomes at a drug health service (DHS) in Sydney, Australia, in the absence of specific funding.

METHODS

A clinic file audit review was conducted of patients who commenced AWM at the service during January 2009-June 2011. Successful completion was defined as daily attendance with ≤1 missed day, or transfer onto opioid substitution treatment.

RESULTS

Of 110 episodes, 69 (63%) were completed. Median patient age was 35 years (range 18-71 years), and most patients (68%) were male. Patients presented primarily for cannabis (33%) or alcohol (30%) withdrawal, followed by heroin (19%) or other opioids (6%), and benzodiazepines (12%). Completion rates varied from 86% for non-heroin opioids to 31% for benzodiazepines. Older age was associated with increased completion: 76% of those aged >35 years completed compared with 50% of those ≤35 years of age. Only 46% of women who commenced withdrawal management completed compared with 71% of men. CONCLUSIONS Most people commencing AWM at the DHS completed the program, indicating AWM can be performed at public drug and alcohol clinics. Service improvements may help increase completion rates among women and patients withdrawing from benzodiazepines. What is known about the topic? WM is not a standalone treatment for substance dependence, but is commonly a first attempt at treatment. AWM is often more acceptable to patients, and cheaper, than in-patient services. What does this paper add? About two-thirds of patients entering an AWM program operating since 2001 continue to complete the program. What are the implications for practitioners? AWM can be carried out successfully through public drug and alcohol services, although clinic staff support is important.

Quantifying the clinical significance of cannabis withdrawal

Background and Aims

Questions over the clinical significance of cannabis withdrawal have hindered its inclusion as a discrete cannabis induced psychiatric condition in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV). This study aims to quantify functional impairment to normal daily activities from cannabis withdrawal, and looks at the factors predicting functional impairment. In addition the study tests the influence of functional impairment from cannabis withdrawal on cannabis use during and after an abstinence attempt.

Methods and Results

A volunteer sample of 49 non-treatment seeking cannabis users who met DSM-IV criteria for dependence provided daily withdrawal-related functional impairment scores during a one-week baseline phase and two weeks of monitored abstinence from cannabis with a one month follow up. Functional impairment from withdrawal symptoms was strongly associated with symptom severity (p = 0.0001). Participants with more severe cannabis dependence before the abstinence attempt reported greater functional impairment from cannabis withdrawal (p = 0.03). Relapse to cannabis use during the abstinence period was associated with greater functional impairment from a subset of withdrawal symptoms in high dependence users. Higher levels of functional impairment during the abstinence attempt predicted higher levels of cannabis use at one month follow up (p = 0.001).

Conclusions

Cannabis withdrawal is clinically significant because it is associated with functional impairment to normal daily activities, as well as relapse to cannabis use. Sample size in the relapse group was small and the use of a non-treatment seeking population requires findings to be replicated in clinical samples. Tailoring treatments to target withdrawal symptoms contributing to functional impairment during a quit attempt may improve treatment outcomes.

Impact of an 18-month, NHS-based, treatment exposure for heroin dependence: results from the London Area Treat 2000 Study

We set out to examine the impact of treatment for heroin dependence on drug use, injecting behavior, health problems, criminality, and physical and mental health over 18 months among heroin-dependent Londoners. A total of 100 heroin users were recruited for this longitudinal prospective cohort study with repeated measures (T0 as baseline, T1 after 9 months, and T2 after 18 months). The psychiatric evaluation and assessment of drug abuse levels were determined by the CIDI and the EuropASI. Additional evaluations included the WHO-DAS II for disability assessment and the UCLA-SSI for social support. The number of days of heroin use in the 30 days previous to each single assessment significantly reduced over time (p < .001). Similar reduction levels were observed for cocaine (p < .05), benzodiazepines (p < .001), and polydrug abuse (p < .001), but not for cannabis and alcohol. The number of injecting occasions reduced in parallel, with increase in days in work and reduction of money spent for drug acquisition activities and money obtained from criminal/illegal activities. The number of subjects experiencing suicidal ideation reduced over time (p < .05). In line with previous suggestions, significant reductions in drug use, criminality, psychopathology, and injecting behavior following treatment exposure for heroin dependence were observed. It is, however, of concern that alcohol and cannabis misuse levels remained unchanged.

Monitoring der Therapie alkohol-bezogener Störungen

Fragestellung: Die Deutsche Suchthilfestatistik (DSHS) stellt eines der größten und umfassendsten Dokumentationssysteme im Suchtbereich weltweit dar. Die Datenlage eröffnet hier ein breites Feld für Trendbeobachtung und Monitoring. Die vorliegende Untersuchung stellt den Versuch dar, anhand einer umschriebenen Störungsgruppe (Alkohol-bezogener Störungen) Veränderungen im Suchthilfesystem deskriptiv abzubilden und systematisch Ursachen innerhalb und außerhalb des Systems gegeneinander abzugrenzen. Methodik: Als Datenbank wurden die anonymisierten Daten der Berliner Suchthilfestatistik aus den Jahren 2004 bis 2008 verwendet (N = 39.219). Beobachtete Variablen der Stichprobe waren Alter bei Behandlungs- und Störungsbeginn, Geschlecht, Schulbildung, Erwerbssitution, Substanz-bezogene Komorbidität, Wohnungssituation und Partnerschaft. Beobachtete Outcome-Variablen waren Behandlungsdauer und Behandlungserfolg. Je nach Niveau und Fragestellung kamen unterschiedliche statistische Verfahren zur Anwendung (z. B. Chi-Quadrat, Regression, Korrelation, t-Test, Varianzanalyse, U-Test, H-Test). Ergebnisse: Die Untersuchung zeigte eine signifikante Reduktion des Therapieerfolgs in ambulanten und eine Verbesserung des Therapieerfolgs in stationären Einrichtungen. Die Behandlungsdauer sank in beiden Bereichen signifikant. Schlussfolgerungen: Diese Trends können vor allem durch soziodemographische Veränderungen der Population erklärt werden, deren Belastung im ambulanten Setting zugenommen und im stationären Bereich abgenommen hat. Die Analysen legen den Schluss nahe, dass in ambulanten und stationären Einrichtungen ein Trend hin zu positiveren Bewertungen von Therapieerfolgen zu beobachten ist.

A randomized trial of two behavioral interventions to improve outcomes following inpatient detoxification for alcohol dependence

Participants (n=150), undergoing inpatient alcohol detoxification, were randomized into 3 groups: treatment as usual (TAU), motivation enhancement therapy (MET), or peer-delivered 12-step facilitation (P-TSF). The main outcome was the initiation of any type of subsequent rehabilitation service (i.e., professional treatment or self-help) within 30 and 90 days of discharge. At the 30-day follow-up interview, there was no significant difference among the groups in the rate of initiation of any type of subsequent care (82%, 74%, and 82%, respectively, p=0.617); however, the MET group had significantly more patients initiate subsequent inpatient treatment by the 90-day follow-up interview compared to the P-TSF group (31% and 61%, respectively, p=0.007) and a greater proportion of MET participants completed subsequent inpatient treatment compared to both the TAU and P-TSF groups. There were no differences in drinking-related outcomes. MET during inpatient detoxification may help patients initiate subsequent inpatient rehabilitation treatment.

Randomized trial of enhanced profiling in substance abuse treatment

A randomized trial of substance abuse treatment programs tested whether "enhanced profiles," consisting of feedback and coaching about performance indicators, improved the performance of residential, methadone, and detoxification programs. These enhanced profiles were reviewed during quarterly on-site visits between October 2005 and July 2007. The performance indicators were the percentage of clients completing referrals to a lower level of care, and the percentage of clients admitted to a higher level of care within 30 days of discharge. Control programs received only "basic profiles," consisting of emailed quarterly printouts of these performance indicators. Effectiveness was evaluated using hierarchical linear models with client-level information nested within agencies and regions of the state. Treatment programs receiving enhanced profiles (n = 74) did not perform significantly differently from those receiving only basic profiles (n = 29) on either performance measure. To improve performance, interventions with greater scope and incentives may be needed.

[Anesthesia in drug addiction]

The growing social problem of drug abuse has increased the likelihood that anesthesiologists will find acute or chronic drug users among patients requiring anesthesia for elective or emergency surgery. We must therefore be aware of the effects drugs have on the organism and their possible pharmacokinetic and pharmacodynamic interactions with anesthetic agents in order to prevent complications during surgery and postoperative recovery. Such knowledge is required for the management of abstinence syndrome or overdose, which pose the greatest potential dangers for the hospitalized drug addict.

Prediction of the outcome of inpatient opiate detoxification treatment: results from a multicenter study

BACKGROUND

Monocentric studies of inpatient opiate detoxification treatment show considerable variability regarding treatment success rates. This multicentric study investigates whether patient characteristics explain the different rates of regular discharge between treatment units.

METHODS

1,017 opiate-dependent patients from 12 detoxification units with similar treatment programs, funding, staffing and equipment were analyzed. Patient data and outcomes were documented by treatment staff using a standard form.

RESULTS

Controlling for center, regular discharge (range: 14-49% between centers) was significantly associated with pre-existing plans for follow-up treatment, previous completed long-term residential and detoxification treatments, fewer unsuccessful detoxification treatments, higher age, later onset of opiate use, and longer duration of use. Controlling for patient characteristics, the center variable was significantly associated with outcome in a multiple logistic regression analysis.

CONCLUSIONS

Regular discharge could best be predicted by patients' plans for follow-up treatment and previous treatment outcomes. Although treatment units had equivalent resources and regulations, and although patient effects were statistically controlled for, there were still considerable center effects. Setting factors as well as actual drop-out processes should be investigated more closely in the future.

Performance contracting to engage detoxification-only patients into continued rehabilitation

In 2006, only 18.7% of Delaware's detoxification patients were admitted to continuing recovery-oriented treatment within 30 days after discharge. In response, Delaware established financial contingencies to (1) maintain 90% detoxification occupancy, (2) make receipt of 10% of the facility's monthly reimbursement contingent on 25% of patients entering treatment, and (3) provide a $500 bonus for every patient with three or more prior detoxification visits who was retained in treatment. Under the performance contract, the detoxification provider (1) maintained the 90% occupancy requirement, (2) achieved the 25% treatment entry target for 7 of 12 months, and (3) observed only 8% (27/337) of detoxification completions that met the targeted length of stay. Continuation to and retention in treatment was even more constrained for patients with three or more prior detoxifications. Contrary to the policy intent, the number of patients with three or more detoxifications in fiscal year (FY) 2008 is nearly triple that of FY 2006. The modest gain in the transition rate was achieved without changes in patient access; the FY 2008 patient population reported significantly higher rates of homelessness and a younger age of first use than before the performance contract in FY 2006. Performance contracting may offer promise for improving transition to treatment rates. However, the unique needs of detoxification patients, the treatment capacity of each level of care to meet patient needs, and the structure of the performance contract must be carefully considered. Performance contracting efforts may be strengthened when service contracts across the system are tightly synchronized.

Cost-effectiveness of extended buprenorphine-naloxone treatment for opioid-dependent youth: data from a randomized trial

AIMS

The objective is to estimate cost, net social cost and cost-effectiveness in a clinical trial of extended buprenorphine-naloxone (BUP) treatment versus brief detoxification treatment in opioid-dependent youth.

DESIGN

Economic evaluation of a clinical trial conducted at six community out-patient treatment programs from July 2003 to December 2006, who were randomized to 12 weeks of BUP or a 14-day taper (DETOX). BUP patients were prescribed up to 24 mg per day for 9 weeks and then tapered to zero at the end of week 12. DETOX patients were prescribed up to 14 mg per day and then tapered to zero on day 14. All were offered twice-weekly drug counseling.

PARTICIPANTS

152 patients aged 15-21 years.

MEASUREMENTS

Data were collected prospectively during the 12-week treatment and at follow-up interviews at months 6, 9 and 12.

FINDINGS

The 12-week out-patient study treatment cost was $1514 (P < 0.001) higher for BUP relative to DETOX. One-year total direct medical cost was only $83 higher for BUP (P = 0.97). The cost-effectiveness ratio of BUP relative to DETOX was $1376 in terms of 1-year direct medical cost per quality-adjusted life year (QALY) and $25,049 in terms of out-patient treatment program cost per QALY. The acceptability curve suggests that the cost-effectiveness ratio of BUP relative to DETOX has an 86% chance of being accepted as cost-effective for a threshold of $100,000 per QALY.

CONCLUSIONS

Extended BUP treatment relative to brief detoxification is cost effective in the US health-care system for the outpatient treatment of opioid-dependent youth.

Opioid antagonists under heavy sedation or anaesthesia for opioid withdrawal

BACKGROUND

Withdrawal (detoxification) is necessary prior to drug-free treatment or as the end point of long-term substitution treatment.

OBJECTIVES

To assess the effectiveness of opioid antagonists to induce opioid withdrawal with concomitant heavy sedation or anaesthesia, in terms of withdrawal signs and symptoms, completion of treatment and adverse effects.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2009), Medline (January 1966 to 11 August 2009), Embase (January 1985 to 2009 Week 32), PsycINFO (1967 to July 2009), and reference lists of articles.

SELECTION CRITERIA

Controlled studies of antagonist-induced withdrawal under heavy sedation or anaesthesia in opioid-dependent participants compared with other approaches, or a different regime of anaesthesia-based antagonist-induced withdrawal.

DATA COLLECTION AND ANALYSIS

One reviewer assessed studies for inclusion, undertook data extraction and assessed quality. Inclusion decisions and the overall process were confirmed by consultation between all authors.

MAIN RESULTS

Nine studies (eight randomised controlled trials) involving 1109 participants met the inclusion criteria for the review.Antagonist-induced withdrawal is more intense but less prolonged than withdrawal managed with reducing doses of methadone, and doses of naltrexone sufficient for blockade of opioid effects can be established significantly more quickly with antagonist-induced withdrawal than withdrawal managed with clonidine and symptomatic medications. The level of sedation does not affect the intensity and duration of withdrawal, although the duration of anaesthesia may influence withdrawal severity. There is a significantly greater risk of adverse events with heavy, compared to light, sedation (RR 3.21, 95% CI 1.13 to 9.12, P = 0.03) and probably with this approach compared to other forms of detoxification.

AUTHORS' CONCLUSIONS

Heavy sedation compared to light sedation does not confer additional benefits in terms of less severe withdrawal or increased rates of commencement on naltrexone maintenance treatment. Given that the adverse events are potentially life-threatening, the value of antagonist-induced withdrawal under heavy sedation or anaesthesia is not supported. The high cost of anaesthesia-based approaches, both in monetary terms and use of scarce intensive care resources, suggest that this form of treatment should not be pursued.

Neurogenetics of dopaminergic receptor supersensitivity in activation of brain reward circuitry and relapse: proposing "deprivation-amplification relapse therapy" (DART)

BACKGROUND AND HYPOTHESIS

It is well known that after prolonged abstinence, individuals who use their drug of choice experience a powerful euphoria that often precipitates relapse. While a biological explanation for this conundrum has remained elusive, we hypothesize that this clinically observed "supersensitivity" might be tied to genetic dopaminergic polymorphisms. Another therapeutic conundrum relates to the paradoxical finding that the dopaminergic agonist bromocriptine induces stronger activation of brain reward circuitry in individuals who carry the DRD2 A1 allele compared with DRD2 A2 allele carriers. Because carriers of the A1 allele relative to the A2 allele of the DRD2 gene have significantly lower D2 receptor density, a reduced sensitivity to dopamine agonist activity would be expected in the former. Thus, it is perplexing that with low D2 density there is an increase in reward sensitivity with the dopamine D2 agonist bromocriptine. Moreover, under chronic or long-term therapy with D2 agonists, such as bromocriptine, it has been shown in vitro that there is a proliferation of D2 receptors. One explanation for this relates to the demonstration that the A1 allele of the DRD2 gene is associated with increased striatal activity of L-amino acid decarboxylase, the final step in the biosynthesis of dopamine. This appears to be a protective mechanism against low receptor density and would favor the utilization of an amino acid neurotransmitter precursor like L-tyrosine for preferential synthesis of dopamine. This seems to lead to receptor proliferation to normal levels and results in significantly better treatment compliance only in A1 carriers.

PROPOSAL AND CONCLUSION

We propose that low D2 receptor density and polymorphisms of the D2 gene are associated with risk for relapse of substance abuse, including alcohol dependence, heroin craving, cocaine dependence, methamphetamine abuse, nicotine sensitization, and glucose craving. With this in mind, we suggest a putative physiological mechanism that may help to explain the enhanced sensitivity following intense acute dopaminergic D2 receptor activation: "denervation supersensitivity." Rats with unilateral depletions of neostriatal dopamine display increased sensitivity to dopamine agonists estimated to be 30 to 100 x in the 6-hydroxydopamine (6-OHDA) rotational model. Given that mild striatal dopamine D2 receptor proliferation occurs (20%-40%), it is difficult to explain the extent of behavioral supersensitivity by a simple increase in receptor density. Thus, the administration of dopamine D2 agonists would target D2 sensitization and attenuate relapse, especially in D2 receptor A1 allele carriers. This hypothesized mechanism is supported by clinical trials utilizing amino acid neurotransmitter precursors, enkephalinase, and catechol-O-methyltransferase (COMT) enzyme inhibition, which have resulted in attenuated relapse rates in reward deficiency syndrome (RDS) probands. If future translational research reveals that dopamine agonist therapy reduces relapse in RDS, it would support the proposed concept, which we term "deprivation-amplification relapse therapy" (DART). This term couples the mechanism for relapse, which is "deprivation-amplification," especially in DRD2 A1 allele carriers with natural D2 agonist therapy utilizing amino acid precursors and COMT and enkepalinase inhibition therapy.

Opioid antagonists with minimal sedation for opioid withdrawal

BACKGROUND

Managed withdrawal is a necessary step prior to drug-free treatment or as the end point of long-term substitution treatment.

OBJECTIVES

To assess the effectiveness of opioid antagonists in combination with minimal sedation to manage opioid withdrawal.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2008), MEDLINE (January 1966-July 2008), EMBASE (January 1985-2008 Week 31), PsycINFO (1967 to 7 August 2008) and reference lists of articles.

SELECTION CRITERIA

Controlled studies of interventions involving the use of opioid antagonists in combination with minimal sedation to manage withdrawal in opioid-dependent participants compared with other approaches or different opioid antagonist regimes.

DATA COLLECTION AND ANALYSIS

One author assessed studies for inclusion and undertook data extraction. Inclusion decisions and the overall process were confirmed by consultation between all authors.

MAIN RESULTS

Nine studies (6 randomised controlled trials), involving 837 participants, met the inclusion criteria for the review.The quality of the evidence is low, but suggests that withdrawal induced by opioid antagonists in combination with an adrenergic agonist is more intense than withdrawal managed with clonidine or lofexidine alone, while the overall severity is less. Delirium may occur following the first dose of opioid antagonist, particularly with higher doses (> 25mg naltrexone).In some situations antagonist-induced withdrawal may be associated with significantly higher rates of completion of treatment, comp[ared to withdrawal managed primarily with adrenergic agonists. However, this outcome has not been produced consistently, and the extent of any benefit is highly uncertain.

AUTHORS' CONCLUSIONS

The use of opioid antagonists combined with alpha(2)-adrenergic agonists is a feasible approach to the management of opioid withdrawal. However, it is unclear whether this approach reduces the duration of withdrawal or facilitates transfer to naltrexone treatment to a greater extent than withdrawal managed primarily with an adrenergic agonist.A high level of monitoring and support is desirable for several hours following administration of opioid antagonists because of the possibility of vomiting, diarrhoea and delirium.Further research is required to confirm the relative effectiveness of antagonist-induced regimes, as well as variables influencing the severity of withdrawal, adverse effects, the most effective antagonist-based treatment regime, and approaches that might increase retention in subsequent naltrexone maintenance treatment.

A double-blind, randomized, parallel group study to compare the efficacy, safety and tolerability of slow-release oral morphine versus methadone in opioid-dependent in-patients willing to undergo detoxification

AIMS

Evaluation of the efficacy and safety of slow-release oral morphine (SROM) compared with methadone for detoxification from methadone and SROM maintenance treatment.

DESIGN

Randomized, double-blind, double-dummy, comparative multi-centre study with parallel groups.

SETTING

Three psychiatric hospitals in Austria specializing in in-patient detoxification.

PARTICIPANTS

Male and female opioid dependents (age > 18 years) willing to undergo detoxification from maintenance therapy in order to reach abstinence.

INTERVENTIONS

Abstinence was reached from maintenance treatment by tapered dose reduction of either SROM or methadone over a period of 16 days.

MEASUREMENTS

Efficacy analyses were based on the number of patients per treatment group completing the study, as well as on the control of signs and symptoms of withdrawal [measured using Short Opioid Withdrawal Scale (SOWS)] and suppression of opiate craving. In addition, self-reported somatic and psychic symptoms (measured using Symptom Checklist SCL-90-R) were monitored.

FINDINGS

Of the 208 patients enrolled into the study, 202 were eligible for analysis (SROM: n = 102, methadone: n = 100). Completion rates were 51% in the SROM group and 49% in the methadone group [difference between groups: 2%; 95% confidence interval (CI): -12% to 16%]. The rate of discontinuation in the study was high mainly because of patients voluntarily withdrawing from treatment. No statistically significant differences between treatment groups were found in terms of signs and symptoms of opiate withdrawal, craving for opiates or self-reported symptoms. SROM and methadone were both well tolerated.

CONCLUSIONS

Detoxification from maintenance treatment with tapered dose reduction of SROM is non-inferior to methadone.

Investigating the effects of San Francisco's Treatment on Demand Initiative on a publicly-funded substance abuse treatment system: a time series analysis

This study investigated effects of San Francisco's Treatment on Demand Initiative, which was designed to increase substance abuse treatment capacity, on the host treatment system. Secondary data on substance abuse treatment admissions, from 1995 through 2000, were obtained from the Department of Public Health, Community Substance Abuse Services, San Francisco, California. Data on 73,988 admissions were retained and grouped by week of admission. Time series analysis was used to assess the effects of time and treatment on demand (independent variables) on weekly number of admissions, sociodemographic characteristics and types of treatment received (dependent variables). As a function of treatment on demand, the number of weekly new admissions significantly increased. Standard outpatient treatment and comprehensive care admissions constituted greater proportions of admissions after treatment on demand. Persons with a primary heroin, cocaine or alcohol problem constituted greater proportions of admissions, and first-time treatment clients constituted a smaller proportion of admissions. Findings suggest that a capacity expansion initiative can increase system wide admissions and redistribute admissions among modalities towards more comprehensive care treatments.

Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence

BACKGROUND

Methadone maintenance was the first widely used opioid replacement therapy to treat heroin dependence, and it remains the best-researched treatment for this problem. Despite the widespread use of methadone in maintenance treatment for opioid dependence in many countries, it is a controversial treatment whose effectiveness has been disputed.

OBJECTIVES

To evaluate the effects of methadone maintenance treatment (MMT) compared with treatments that did not involve opioid replacement therapy (i.e., detoxification, offer of drug-free rehabilitation, placebo medication, wait-list controls) for opioid dependence.

SEARCH STRATEGY

We searched the following databases up to Dec 2008: the Cochrane Controlled Trials Register, EMBASE, PubMED, CINAHL, Current Contents, Psychlit, CORK [www. state.vt.su/adap/cork], Alcohol and Drug Council of Australia (ADCA) [www.adca.org.au], Australian Drug Foundation (ADF-VIC) [www.adf.org.au], Centre for Education and Information on Drugs and Alcohol (CEIDA) [www.ceida.net.au], Australian Bibliographic Network (ABN), and Library of Congress databases, available NIDA monographs and the College on Problems of Drug Dependence Inc. proceedings, the reference lists of all identified studies and published reviews; authors of identified RCTs were asked about other published or unpublished relevant RCTs.

SELECTION CRITERIA

All randomised controlled clinical trials of methadone maintenance therapy compared with either placebo maintenance or other non-pharmacological therapy for the treatment of opioid dependence.

DATA COLLECTION AND ANALYSIS

Reviewers evaluated the papers separately and independently, rating methodological quality of sequence generation, concealment of allocation and bias. Data were extracted independently for meta-analysis and double-entered.

MAIN RESULTS

Eleven studies met the criteria for inclusion in this review, all were randomised clinical trials, two were double-blind. There were a total number of 1969 participants. The sequence generation was inadequate in one study, adequate in five studies and unclear in the remaining studies. The allocation of concealment was adequate in three studies and unclear in the remaining studies. Methadone appeared statistically significantly more effective than non-pharmacological approaches in retaining patients in treatment and in the suppression of heroin use as measured by self report and urine/hair analysis (6 RCTs, RR = 0.66 95% CI 0.56-0.78), but not statistically different in criminal activity (3 RCTs, RR=0.39; 95%CI: 0.12-1.25) or mortality (4 RCTs, RR=0.48; 95%CI: 0.10-2.39).

AUTHORS' CONCLUSIONS

Methadone is an effective maintenance therapy intervention for the treatment of heroin dependence as it retains patients in treatment and decreases heroin use better than treatments that do not utilise opioid replacement therapy. It does not show a statistically significant superior effect on criminal activity or mortality.

Buprenorphine for the management of opioid withdrawal

BACKGROUND

Managed withdrawal is a necessary step prior to drug-free treatment or as the end point of substitution treatment.

OBJECTIVES

To assess the effectiveness of interventions involving the use of buprenorphine to manage opioid withdrawal, for withdrawal signs and symptoms, completion of withdrawal and adverse effects.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2008), MEDLINE (January 1966 to July 2008), EMBASE (January 1985 to 2008 Week 31), PsycINFO (1967 to 7 August 2008) and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials of interventions involving the use of buprenorphine to modify the signs and symptoms of withdrawal in participants who were primarily opioid dependent. Comparison interventions involved reducing doses of methadone, alpha(2)-adrenergic agonists, symptomatic medications or placebo, or different buprenorphine-based regimes.

DATA COLLECTION AND ANALYSIS

One author assessed studies for inclusion and methodological quality, and undertook data extraction. Inclusion decisions and the overall process was confirmed by consultation between all authors.

MAIN RESULTS

Twenty-two studies involving 1736 participants were included. The major comparisons were with methadone (5 studies) and clonidine or lofexidine (12 studies). Five studies compared different rates of buprenorphine dose reduction.Severity of withdrawal is similar for withdrawal managed with buprenorphine and withdrawal managed with methadone, but withdrawal symptoms may resolve more quickly with buprenorphine. It appears that completion of withdrawal treatment may be more likely with buprenorphine relative to methadone (RR 1.18; 95% CI 0.93 to 1.49, P = 0.18) but more studies are required to confirm this.Relative to clonidine or lofexidine, buprenorphine is more effective in ameliorating the symptoms of withdrawal, patients treated with buprenorphine stay in treatment for longer (SMD 0.92, 95% CI 0.57 to 1.27, P < 0.001), and are more likely to complete withdrawal treatment (RR 1.64; 95% CI 1.31 to 2.06, P < 0.001). At the same time there is no significant difference in the incidence of adverse effects, but drop-out due to adverse effects may be more likely with clonidine.

AUTHORS' CONCLUSIONS

Buprenorphine is more effective than clonidine or lofexidine for the management of opioid withdrawal. Buprenorphine may offer some advantages over methadone, at least in inpatient settings, in terms of quicker resolution of withdrawal symptoms and possibly slightly higher rates of completion of withdrawal.

Intensity of opiate withdrawal in relation to the 825C>T polymorphism of the G-protein beta 3 subunit gene

OBJECTIVES

The intensity of withdrawal in opiate dependence shows a high inter-individual variability. The 825C>T polymorphism (rs5443) of the G-protein beta 3 (GNB3) subunit gene has a strong influence on clinical signs of sympathetic activity in cardiac research. This study was carried out in order to test the hypothesis that carriers of the T allele have an increased sympathetic activity in opiate withdrawal.

METHODS

Thirty-nine monovalent opiate addicted patients consecutively admitted to a detoxification ward were investigated. The main parameter for sympathetic activity was the pulse rate in the first 3 days after the regular end of gradual methadone reduction.

RESULTS

Thirty-three out of 39 patients achieved a drug-free state: 22 carried a T allele (TT, CT), 11 belonged to the CC genotype group. The pulse rate was significantly (p<0.05) raised in the T allele group compared to the CC genotype group on the first 2 days after stopping methadone administration. In addition, about a third of the T allele carriers needed clonidine treatment on the respective days, but only one patient among the 11 CC homozygotes. There was no significant difference between groups in systolic and diastolic blood pressures as well as in subjective withdrawal ratings.

CONCLUSION

A group difference regarding pulse rate could be observed in a small sample and despite a higher degree of concomitant clonidine medication in T allele carriers. The failure to detect group differences in blood pressure and self-rated withdrawal symptoms may be attributed to the more complex regulation of blood pressure and the known weak correlation between objective and subjective withdrawal symptoms.