Heroin-assisted treatment in the Netherlands: History, findings, and international context

Prevalence of stimulant use and the role of opioid agonist treatment among people who inject drugs in France: Results from the COSINUS cohort study

INTRODUCTION

The co-use of stimulants and opioids, including opioid agonist treatment (OAT), is very prevalent worldwide. A large body of data exists on the association between stimulant use and its health complications, and on OAT effectiveness among people with opioid use disorder. However, few data exist on stimulant-opioid co-use among people receiving OAT. Using data from the COSINUS cohort study, we investigated the association between the type of OAT and problematic stimulant use among persons who inject drugs (PWID).

METHODS

COSINUS is a 12-month French cohort study of 665 PWID. Data were collected in face-to-face interviews at enrolment, at 6 and 12 months. We defined problematic stimulant use as daily use of and/or injecting stimulants. We used Bayesian model averaging (BMA) to identify factors associated with problematic stimulant use.

RESULTS

At baseline, 76% (n = 505) of the participants reported problematic stimulant use. The optimal model from the BMA estimation showed that, after adjusting on social precarity and daily injection, participants on prescribed morphine sulfate as an OAT (compared with methadone) and those who use daily unprescribed buprenorphine were less likely to report problematic stimulant use.

DISCUSSION AND CONCLUSIONS

Our work highlights the high prevalence of problematic stimulant use among PWID in France but also the potential association between the type of OAT taken and stimulant use, by suggesting a protective effect of morphine sulfate on stimulant use. Since it has a higher intrinsic activity than other opioids, PWID on this OAT may be less interested in stimulants. Our findings warrant further investigation in clinical studies.

Experiences of Healthcare Professionals Working in Injectable Opioid Agonist Treatment Programs: A Qualitative Thematic Analysis

BACKGROUND

Injectable opioid agonist treatment (iOAT) programs are increasing as a method of harm reduction for opioid use disorder. Although there have been numerous studies of client experience in iOAT programs, there have been few studies on the experiences on healthcare professionals working in these programs.

AIM

In this study, we aimed to understand the experiences and perspectives of healthcare professionals in iOAT programs. This study is among the first to explore the experiences of healthcare professionals in an operational iOAT program, with the aim of making workforce recommendations to enhance the sustainability of iOAT programs.

METHODS

We conducted a secondary analysis using a thematic analysis approach with qualitative interview transcripts.

RESULTS

Sixteen participants were interviewed, and we analyzed the transcripts, identifying three major themes: healthcare professionals' experiences in the iOAT program, approaches to work, and navigating practice issues. Working in iOAT was rewarding for participants because of the changes the program created in clients' lives. Participants reported that building trusting relationships with iOAT clients was key to the client's success. Healthcare professionals' approaches to their work varied, where they adopted either client-centered care or rules-based approaches. Healthcare professionals' experiences were shaped by program structure, the need to adapt their work, and building relationships with other healthcare services. Managing limited resources was a challenge for participants.

CONCLUSION

Supportive work environments can foster relationships between healthcare professionals and clients, for success in iOAT programs. Healthcare professionals require adequate support and staffing to provide high-quality care.

Challenges for the implementation of injectable opioid agonist treatment: a scoping review

BACKGROUND AND AIMS

Injectable opioid agonist treatment (iOAT) is a valuable, patient-centred, evidence based intervention. However, limited information exists on contextual factors that may support or hinder iOAT implementation and sustainability. This study aims to examine existing research on iOAT using diacetylmorphine and hydromorphone, focusing on identifying the key barriers and facilitators to its successful implementation.

METHODS

A systematic search was conducted in the MEDLINE and PsycInfo databases (via Ovid) from inception to February 2024, supplemented by a comprehensive grey literature search. No restrictions were applied regarding publication type, year, or geographic location. Articles were independently screened by two reviewers. Eligible articles described the feasibility, implementation, and/or evaluation of iOAT in one or more countries, presenting perspectives on receiving, administering, or governing iOAT.

RESULTS

Forty-four publications were selected for inclusion. Barriers identified through thematic analysis included public acceptance concerns such as medication diversion, increased crime, and the Honey-Pot effect. Legal and ethical challenges identified involved enacting changes in law to make certain substances available as a medically controlled options for treatment, and addressing patient consent issues. Negative media coverage and public controversies were found to undermine acceptance, and high start-up costs especially for security, facility access, and economic feasibility were seen as additional obstacles. Regulatory barriers and stringent protocols were the most frequently cited limiting factors by patients and providers. Facilitators included the integration of trial prescriptions into comprehensive drug policy strategies and publishing data for evidence-based debates, together with ethics committees ensuring compliance with ethical standards. Developing information strategies and addressing opponents' claims improved public perception. Cost-effectiveness evidence was found to support long-term implementation, while flexible treatment protocols, inclusive spaces, and affirming therapeutic relationships were seen as important facilitators to enhance patient engagement and treatment effectiveness.

CONCLUSIONS

Successful implementation of iOAT requires balancing political and social acceptability with scientific integrity, alongside strategic communication and public outreach. Further research is needed to enhance the transferability of findings across diverse socio-political contexts and address key influencing factors associated with iOAT programs.

Narkotikapolitikk i endring: Heroinklinikkenes oppkomst i Norge

Bruk av heroin for behandling av personer med rusmiddelavhengighet er nytt i Norge. Heroinklinikkene markerer et brudd med de siste ti-årenes narkotikapolitikk og rusbehandling. I denne artikkelen beskrives endringene i myndighetenes forståelse av «narkotikaproblemet» og hvordan det bør håndteres. Heroinklinikkene utforskes som uttrykk for slik endring. For å forklare hvorfor og hvordan disse omstridte klinikkene ble en realitet presenteres en to-delt analyse: først av ideologiske endringer i narkotikapolitikken fra 1960-tallet til i dag, og så av den politiske debatten om heroinklinikkene som tok fart fra 2007. Artikkelen argumenterer for at de ideologiske endringene på det narkotikapolitiske feltet i stor grad muliggjorde den senere politiske prosessen som endte med etablering av heroinklinikkene. Analysen identifiserer tre atskilte forståelser av narkotikaproblemet som har eksistert gjennom hele 60-års perioden, og tre motstridende tilnærminger til heroinklinikkene som ble synlige i den politiske debatten. Ved å diskutere sammenfallet mellom disse forståelsene og tilnærmingene over tid bidrar artikkelen med å forklare heroinklinikkenes oppkomst i en bredere narkotikapolitisk sammenheng.

Patients' satisfaction with heroin-assisted treatment: a qualitative study

BACKGROUND

Heroin-assisted treatment (HAT) involves supervised dispensing of medical heroin (diacetylmorphine) for people with opioid use disorder. Clinical evidence has demonstrated the effectiveness of HAT, but little is known about the self-reported satisfaction among the patients who receive this treatment. This study presents the first empirical findings about the patients' experiences of, and satisfaction with, HAT in the Norwegian context.

METHODS

Qualitative in-depth interviews with 26 patients in HAT were carried out one to two months after their enrollment. Analysis sought to identify the main benefits and challenges that the research participants experienced with this treatment. An inductive thematic analysis was conducted to identify the main areas of benefits and challenges. The benefits were weighed against the challenges in order to assess the participants' overall level of treatment satisfaction.

RESULTS

Analysis identified three different areas of experienced benefits and three areas of challenges of being in this treatment. It outlines how the participants' everyday lives are impacted by being in the treatment and how this, respectively, results from the treatment's medical, relational, or configurational dimensions. We found an overall high level of treatment satisfaction among the participants. The identification of experienced challenges reveals factors that reduce satisfaction and thus may hinder treatment retention and positive treatment outcomes.

CONCLUSIONS

The study demonstrates a novel approach to qualitatively investigate patients' treatment satisfaction across different treatment dimensions. The findings have implications for clinical practice by pointing out key factors that inhibit and facilitate patients' satisfaction with HAT. The identified importance of the socio-environmental factors and relational aspect of the treatment has further implications for the provision of opioid agonist treatment in general.

Is use of opioid agonist treatment associated with broader primary healthcare use among men with recent injecting drug use histories following release from prison? A prospective cohort study

BACKGROUND

A precipitous decline in health status among people recently released from prison is common. In Victoria, Australia, opioid agonist treatment (OAT) in the community involves frequent contact with primary care, potentially facilitating broader use of primary healthcare services. Among a cohort of men who injected drugs regularly pre-imprisonment, we estimated differences in rates of primary healthcare use and medication dispensation between people who did and did not receive OAT post-release.

METHODS

Data came from the Prison and Transition Health Cohort Study. Three-month post-release follow-up interviews were linked with primary care and medication dispensation records. Generalised linear models were fit with one exposure (OAT: none/partial/complete) for 13 outcomes relating to primary healthcare use, pathology testing, and medication dispensation, adjusted for other covariates. Coefficients were reported as adjusted incidence rate ratios (AIRR).

RESULTS

Analyses included 255 participants. Compared to no OAT use, both partial and complete OAT use were associated with increased rates of standard (AIRR: 3.02, 95%CI: 1.88-4.86; AIRR: 3.66, 95%CI: 2.57-5.23), extended (AIRR: 2.56, 95%CI: 1.41-4.67; AIRR: 2.55, 95%CI: 1.60-4.07) and mental health-related (AIRR: 2.71, 95%CI: 1.42-5.20; AIRR: 2.27, 95%CI: 1.33-3.87) general practitioner (GP) consultations, total medication (AIRR: 1.88, 95%CI: 1.19-2.98; AIRR: 2.40, 95%CI: 1.71-3.37), benzodiazepine (AIRR: 4.99, 95%CI: 2.81-8.85; AIRR: 8.30, 95%CI: 5.28-13.04) and gabapentinoid (AIRR: 6.78, 95%CI: 3.34-13.77; AIRR: 4.34, 95%CI: 2.37-7.94) dispensations, respectively. Partial OAT use was also associated with increased after-hours GP consultations (AIRR: 4.61, 95%CI: 2.24-9.48) and complete OAT use? with increased pathology utilisation (e.g. haematological, chemical, microbiological or immunological tissue/sample testing; AIRR: 2.30, 95%CI: 1.52-3.48).

CONCLUSION

We observed higher rates of primary healthcare use and medication dispensation among people who reported partial and complete OAT use post-release. Findings suggest that access to OAT post-release may have a collateral benefit in supporting broader health service utilisation, underscoring the importance of retention in OAT after release from prison.

Discontinuation of opioid agonist treatment following release from prison in a cohort of men who injected drugs prior to imprisonment in Victoria, Australia: A discrete-time survival analysis

BACKGROUND

Retention in opioid agonist treatment (OAT) following release from prison is associated with improved outcomes, however factors associated with post-release OAT discontinuation in Australia are poorly understood. We examined post-release OAT discontinuation in a cohort of men who engaged in approximately monthly injecting drug use (IDU) prior to imprisonment in Victoria, Australia.

METHODS

Longitudinal data were used to calculate incidence of first-event post-release OAT discontinuation among men released from prison receiving OAT, and single-event discrete-time survival methods were used to estimate associations with post-release OAT discontinuation.

RESULTS

Among 110 participants, 55 OAT discontinuations were observed in the two years post-release, an overall crude incidence rate (IR) of 46 per 100 person-years (PY) (95 % confidence interval [95 %CI]: 36-60 per 100PY). Incidence was greatest between release from prison and first follow-up (IR: 84 per 100PY, 95 %CI: 62-116 per 100PY). Initiating OAT during index imprisonment (versus transitioning from community OAT; adjusted hazard rate [AHR]: 2.17, 95 %CI: 1.14-4.13) and identifying as Aboriginal and/or Torres Strait Islander (AHR: 4.95, 95 %CI: 2.00-12.25) were associated with an increased hazard of OAT discontinuation.

CONCLUSION

In a cohort of men with recent histories of IDU released from prison receiving OAT, half reported OAT discontinuation within two years of release from prison, with incidence of discontinuation greatest soon after prison-release. Targeted support for men who initiate OAT during episodes of imprisonment and Aboriginal and/or Torres Strait Islander peoples is necessary to reduce incidence of OAT discontinuation among people at greatest risk of discontinuation.

Stimulant use disorder diagnosis and opioid agonist treatment dispensation following release from prison: a cohort study

BACKGROUND

Concurrent opioid and stimulant use is on the rise in North America. This increasing trend of use has been observed in the general population, and among people released from prison in British Columbia (BC), who face an elevated risk of overdose post-release. Opioid agonist treatment is an effective treatment for opioid use disorder and reduces risk of overdose mortality. In the context of rising concurrent stimulant use among people with opioid use disorder, this study aims to investigate the impact of stimulant use disorder on opioid agonist treatment dispensation following release from prison in BC.

METHODS

Linked health and corrections records were retrieved for releases between January 1^st 2015 and December 29^th 2018 (N = 13,380). Hospital and primary-care administrative health records were used to identify opioid and stimulant use disorder and mental illness. Age, sex, and health region were derived from BC's Client Roster. Incarceration data were retrieved from provincial prison records. Opioid agonist treatment data was retrieved from BC's provincial drug dispensation database. A generalized estimating equation produced estimates for the relationship of stimulant use disorder and opioid agonist treatment dispensation within two days post-release.

RESULTS

Cases of release among people with an opioid use disorder were identified (N = 13,380). Approximately 25% (N = 3,328) of releases ended in opioid agonist treatment dispensation within two days post-release. A statistically significant interaction of stimulant use disorder and mental illness was identified. Stratified odds ratios (ORs) found that in the presence of mental illness, stimulant use disorder was associated with lower odds of obtaining OAT [(OR) = 0.73, 95% confidence interval (CI) = 0.64-0.84)] while in the absence of mental illness, this relationship did not hold [OR = 0.89, 95% CI = 0.70-1.13].

CONCLUSIONS

People with mental illness and stimulant use disorder diagnoses have a lower odds of being dispensed agonist treatment post-release compared to people with mental illness alone. There is a critical need to scale up and adapt opioid agonist treatment and ancillary harm reduction, and treatment services to reach people released from prison who have concurrent stimulant use disorder and mental illness diagnoses.

Concurrent use of opioids and stimulants and risk of fatal overdose: A cohort study

Background

Stimulant use has been rising among people with opioid use disorder in recent years in North America, alongside a parallel rise in illicit drug toxicity (overdose) deaths. This study aimed to examine the association between stimulant use and overdose mortality.

Methods

Data from a universal health insurance client roster were used to identify a 20% random general population sample (aged ≥12) in British Columbia, Canada between January 1 2015 and December 31 2018 (N = 1,089,682). Provincial health records were used to identify people who used opioids and/or stimulants. Fatal overdose observed during follow-up (January 12,015- December 312,018) was retrieved from Vital Statistics Death Registry and BC Coroners Service Data. Potential confounders including age, sex, health region, comorbidities and prescribed medications were retrieved from the provincial client roster and health records.

Results

We identified 7460 people who used stimulants and or opioids. During follow-up there were 272 fatal overdose events. People who used both opioids and stimulants had more than twice the hazard of fatal overdose (HR: 2.02, 95% CI: 1.47-2.78, p < 0.001) compared to people who used opioids only. The hazard of death increased over time among people who used both opioids and stimulants.

Conclusions

There is an urgent need to prioritize the service needs of people who use stimulants to reduce overdose mortality in British Columbia. Findings have relevance more broadly in other North American settings, where similar trends in opioid and stimulant polysubstance use have been observed.

The suitability of oral diacetylmorphine in treatment-refractory patients with heroin dependence: A scoping review

OBJECTIVE

To review the scientific literature on the pharmacokinetics, pharmacodynamics and clinical efficacy and safety of (supervised) oral diacetylmorphine for patients with severe heroin dependence.

METHODS

The PubMed, Embase, Web of Science and PsycINFO databases were searched. Eleven published studies were identified and selected based on defined eligibility and exclusion criteria.

RESULTS

Four pharmacokinetic studies reported negligible plasma concentrations of diacetylmorphine and its active metabolite 6-monacetylmorphine. Among six pharmacodynamic studies, three trials showed that oral diacetylmorphine reduced opioid withdrawal symptoms, one open-label pilot study reported that two patients experienced a modest 'rush' after oral diacetylmorphine and two studies found that patients could not distinguish between oral diacetylmorphine, methadone, or morphine. Regarding the clinical studies, a Swiss prospective cohort study in patients with heroin dependence showed high retention rates of oral diacetylmorphine treatment with few serious adverse events, whereas in the Canadian SALOME trial, oral diacetylmorphine treatment was prematurely discontinued because treatment retention of oral diacetylmorphine was lower than injectable diacetylmorphine maintenance treatment. Finally, two case studies illustrate the limitations and potential problems of oral diacetylmorphine in the treatment of treatment-refractory heroin dependent patients.

CONCLUSIONS

Based on all published data, it is unlikely that oral diacetylmorphine produces a substantial 'rush'. Prescription of oral diacetylmorphine might therefore be effective only for treatment-refractory patients with heroin dependence (i) as maintenance treatment for those who never injected or inhaled opioids; (ii) as maintenance treatment for those who want to switch from injection to oral administration of diacetylmorphine; and/or (iii) to reduce opioid withdrawal symptoms.

Exploring the effectiveness of dextroamphetamine for the treatment of stimulant use disorder: a qualitative study with patients receiving injectable opioid agonist treatment

Background

A high proportion of people receiving both oral and injectable opioid agonist treatment report concurrent use of stimulants (i.e. cocaine and or amphetamines), which has been associated with higher rates of continued illicit opioid use and treatment dropout. A recent randomized controlled trial demonstrated the effectiveness of dextroamphetamine (a prescribed stimulant) at reducing craving for and use of cocaine among patients receiving injectable opioid agonist treatment. Following this evidence, dextroamphetamine has been prescribed to patients with stimulant use disorder at a clinic in Vancouver. This study investigates perceptions of the effectiveness of dextroamphetamine from the perspective of these patients.

Methods

Data were collected using small focus groups and one-on-one interviews with patients who were currently or formerly receiving dextroamphetamine (n = 20). Thematic analysis was conducted using an iterative approach, moving between data collection and analysis to search for patterns in the data across transcripts. This process led to the defining and naming of three central themes responding to the research question.

Results

Participants reported a range of stimulant use types, including cocaine (n = 8), methamphetamine (n = 8), or both (n = 4). Three central themes were identified as relating to participants’ perceptions of the effectiveness of the medication: 1) achieving a substitution effect (i.e. extent to which dextroamphetamine provided a substitution for the effect they received from use of illicit stimulants); 2) Reaching a preferred dose (i.e. speed of titration and effect of the dose received); and 3) Ease of medication access (i.e. preference for take home doses (i.e. carries) vs. medication integrated into care at the clinic).

Conclusion

In the context of continued investigation of pharmacological treatments for stimulant use disorder, the present study has highlighted how the study of clinical outcomes could be extended to account for factors that contribute to perceptions of effectiveness from the perspective of patients. In practice, elements of treatment delivery (e.g. dosing and dispensation protocols) can be adjusted to allow for various scenarios (e.g. on site vs. take home dosing) by which dextroamphetamine and other pharmacological stimulants could be implemented to provide “effective” treatment for people with a wide range of treatment goals and needs.

Use of sustained release dextroamphetamine for the treatment of stimulant use disorder in the setting of injectable opioid agonist treatment in Canada: a case report

BACKGROUND

For people with opioid use disorder who are not responding to oral opioid agonist treatment, evidence supports the effectiveness of injectable opioid agonist treatment with injectable hydromorphone (an opioid analgesic) and diacetylmorphine (pharmaceutical grade heroin). While this treatment is effective at reducing illicit opioid use, concurrent cocaine use is prevalent. Dextroamphetamine (a central nervous system stimulant) has been found to be a safe and effective treatment for cocaine dependence among people receiving injectable opioid agonist treatment in Europe. We present the first report of dextroamphetamine prescribing offered for the treatment of stimulant use disorder among a patient receiving iOAT outside of a clinical trial. This case report can be used to inform clinical practice in the treatment of cocaine use disorder, an area where interventions are currently lacking.

CASE PRESENTATION

Dextroamphetamine was prescribed to a 51-year-old male who was diagnosed with concurrent opioid and stimulant use disorder in an injectable opioid agonist treatment clinic in Vancouver, Canada. He reported smoking crack cocaine daily for more than two decades and was experiencing health consequences associated with this use. He presented to his routine physician visit with the goal of reducing his cocaine use and was prescribed dextroamphetamine for the treatment of stimulant use disorder. After 4-weeks the patient was tolerating the medication with no observed adverse events and was achieving his therapeutic goal of reducing his cocaine use.

CONCLUSIONS

Dextroamphetamine can be prescribed to support patients with stimulant use disorder to reduce or stop their use of cocaine. The case demonstrated that when dextroamphetamine was prescribed, a significant reduction in cocaine use was experienced among a patient that had been regularly using cocaine on a daily basis for many years. Daily contact with care for the opioid medication promoted adherence to the stimulant medication and allowed for monitoring of dose and tolerance. Settings where patients are in regular contact with care such as oral and injectable opioid agonist treatment clinics serve as a suitable location to integrate dextroamphetamine prescribing for patients that use illicit stimulants to reduce use and associated harms.

Association of Serotonin Transporter (SERT) Polymorphisms with Opioid Dependence and Dimensional Aspects of Cocaine Use in a Caucasian Cohort of Opioid Users

INTRODUCTION

A functional tandem repeat polymorphism in the promoter of the serotonin transporter (SERT) gene (SLC6A4) has been studied for association to neuropsychiatric conditions, including substance use disorders. Short (S) forms of this repeat result in reduced transcription, and presumably greater synaptic levels of serotonin, which are involved in opioid and cocaine-induced reward. Dual exposure to heroin and cocaine is a common pattern of poly-drug use and is associated with considerable morbidity. We hypothesize that SLC6A4 variants are associated with cocaine exposure in subjects with an opioid dependence diagnosis (OD), and also in non-dependent opioid users (NOD). Other single nucleotide polymorphisms (SNPs) of SLC6A4 may also be likewise associated.

MATERIALS AND METHODS

This study determined whether variants of the SLC6A4 promoter repeats and two intronic SNPs, rs16965628 and rs2066713, are associated with categorical diagnoses of opioid dependence (DSM-IV criteria) and with dimensional aspects of cocaine use, in a Caucasian cohort (n=591). Three groups of subjects were examined: (1) 276 subjects with opioid dependence diagnosis (OD); (2) 163 subjects who had used opioids for non-medical reasons but never had an opioid dependence diagnosis (NOD); (3) 152 healthy controls (HC).

RESULTS

Aside from high exposure to heroin in the OD group, relatively high exposure to cocaine was detected in both OD and NOD groups. The SERT repeat genotype (classified as "long-long" [LL] versus "short-long" plus "short-short" [SL+SS]) was not associated with categorical opioid dependence diagnoses. A nominally significant association was identified with the [SL+SS] genotype of SLC6A4 and cocaine KMSK scores ≥"cutpoint" for a cocaine dependence diagnosis (p=0.026). The [SL+SS] genotype was associated with more rapid cocaine escalation than the LL genotype. No significant associations of rs16965628 and rs2066713 SNPs were found overall.

CONCLUSION

The functional SERT promoter tandem repeat genotype may be associated to heavy cocaine exposure and more rapid escalation of cocaine use, in persons with and without opioid dependence diagnosis.

Longitudinal patterns of cocaine use among patients receiving injectable hydromorphone or diacetylmorphine for the treatment of opioid use disorder: A growth curve modeling approach

BACKGROUND AND AIMS

Cocaine use is prevalent among people receiving injectable opioid agonist treatment. Investigations of cocaine use in this population have been descriptive and the potential heterogeneity existing in patterns of use have not been characterized. As such, among patients receiving injectable opioid agonist treatment, this study aimed to: 1) quantify intra- and inter-individual variation in cocaine use over 24-months and; 2) determine how predictors of interest explained this variation.

METHODS

Participants were patients receiving injectable opioid agonist treatment for opioid use disorder. Study visits were completed at baseline prior to receiving treatment, and 3,6,9,12,18, and 24 months after baseline. A multi-level regression approach to growth curve modeling was employed to estimate and explain intra- (within-person) and inter-individual (between-person) variation in cocaine use.

RESULTS

Significant intra and inter-individual variation in cocaine use was identified over 24-months. Treatment engagement was on average associated with reductions in the prior month number of days of cocaine use (range: 0-30)(Estimate (standard error): -0.05(0.02), p = 0.003). On average, men reported less cocaine use compared to women (Estimate (standard error): -5.91(1.57), p=<0.001), and participants reporting ever regularly using cocaine at baseline reported more cocaine use over 24-months compared to participants reporting never regularly using cocaine (Estimate (standard error): 4.72 (1.91), p = 0.013).

CONCLUSIONS

Significant reductions in cocaine use were observed and significant heterogeneity in patterns of cocaine use was identified. These heterogeneous cocaine use profiles suggest that an individualized approach to care will be critical in responding to patients' cocaine use in injectable opioid agonist treatment.

Clinical effects beyond cocaine use of sustained-release dexamphetamine for the treatment of cocaine dependent patients with comorbid opioid dependence: secondary analysis of a double-blind, placebo-controlled randomized trial

BACKGROUND AND AIMS

Sustained-release (SR) formulations of dexamphetamine and mixed amphetamine salts have shown positive effects in the treatment of patients with a cocaine use disorder. We previously demonstrated the efficacy of SR-dexamphetamine for patients with cocaine dependence in terms of cocaine use reductions. In this secondary analysis, we assessed whether SR-dexamphetamine treatment also improves the health status of these patients.

DESIGN

Multi-centre randomized, double-blind placebo-controlled trial.

SETTING

Four supervised heroin-assisted treatment (HAT) out-patient clinics in the Netherlands. In HAT, methadone treatment-refractory opioid-dependent patients can self-administer individually titrated doses of pharmaceutical grade diacetylmorphine, coprescribed with oral methadone.

PARTICIPANTS

Seventy-three cocaine-dependent patients (90% males; average age = 48.7 years), participating in HAT for their treatment-refractory comorbid opioid dependence.

INTERVENTIONS

Twelve weeks pharmacotherapy with once-daily, supervised intake of two tablets of SR-dexamphetamine (2 × 30 mg/day) or two identical placebo tablets.

MEASUREMENTS

Assessment every 4 weeks: cocaine use (time-line follow-back), physical health (Maudsley Addiction Profile-Health Symptoms Scale), mental health (Brief Symptom Inventory) and illegal activities (Addiction Severity Index). Primary outcome was 'overall health', a dichotomous, multi-domain response index based on physical health, mental health and social functioning.

FINDINGS

Compared with placebo, SR-dexamphetamine resulted in larger increases in the number of cocaine abstinent days (P = 0.004) and the proportion of overall health treatment responders (P = 0.045) from the 4 weeks preceding baseline to the final 4 weeks of treatment. While the number of cocaine abstinent days was not associated with overall health in the total study sample, it was positively associated with overall health among patients in poor overall health at the start of SR-dexamphetamine treatment (n = 50), i.e. patients with the potential to improve on this multi-domain response index (odds ratio = 1.076; 95% confidence interval = 1.025-1.130).

CONCLUSIONS

SR-dexamphetamine reduces cocaine use and may improve clinically relevant health-related outcomes in patients with cocaine dependence who are participating in heroin-assisted treatment for their comorbid heroin dependence.

Building healthcare provider relationships for patient-centered care: A qualitative study of the experiences of people receiving injectable opioid agonist treatment

BACKGROUND

Injectable opioid agonist treatment (iOAT) was designed as a pragmatic and compassionate approach for people who have not benefitted from medication assisted treatment with oral opioids (e.g., methadone). While, a substantial body of clinical trial evidence has demonstrated the safety and effectiveness of iOAT, considerably less is known about the patient-centered aspects of this treatment and their role in self-reported treatment goals and outcomes. The aim of this study was to explore participants' experiences in iOAT as they broadly relate to the domains of patient-centered care. A secondary goal was to explore how these experiences affected participants' self-reported treatment outcomes.

METHODS

A qualitative methodology, and constructivist grounded theory approach, was used to guide sampling, data collection and analysis. A total of 30 in-depth interviews were conducted with people receiving iOAT in North America's first clinic. Audio-recordings for each semi-structured interview were transcribed and read repeatedly. The strategy of constant comparison was used through iterative stages of line-by-line, focused and theoretical coding until theoretical saturation was achieved.

RESULTS

"Building healthcare provider relationships for patient-centered care in iOAT" was the emergent core concept. Healthcare provider relationships were established through two interrelated processes: 'Opening up' was attributed to the positive environment, and to feeling understood and supported by healthcare providers. 'Being a part of care' emerged as participants felt safe to ask for what was needed and had opportunities to collaborate in treatment decisions. These processes established a foundation in which participants experienced care that was responsive to their individual dose, health and psychosocial needs.

CONCLUSIONS

The core concept suggested that therapeutic relationships were fundamental to experiences of patient-centered care in iOAT. When relationships were respectful and understanding, participants received individualized and holistic care in iOAT. These findings offer a valuable example of how therapeutic relationships can be strengthened in other substance use treatment settings, particularly when responding to the diverse treatment needs of clients.

VMAT2 gene (SLC18A2) variants associated with a greater risk for developing opioid dependence

Aim: To determine if selected serotonergic and noradrenergic gene variants are associated with heroin addiction. Subjects & methods: A total of 126 variants in 19 genes in subjects with Dutch European ancestry from The Netherlands. Subjects included 281 opioid-dependent volunteers in methadone maintenance or heroin-assisted treatment, 163 opioid-exposed but not opioid-dependent volunteers who have been using illicit opioids but never became opioid-dependent and 153 healthy controls. Results: Nominal associations were indicated for 20 variants in six genes including an experiment-wise significant association from the combined effect of three SLC18A2 SNPs (rs363332, rs363334 and rs363338) with heroin dependence (p_final = 0.047). Conclusion: Further studies are warranted to confirm and elucidate the role of these variants in the vulnerability to opioid addiction.

Association of variants of prodynorphin promoter 68-bp repeats in caucasians with opioid dependence diagnosis: Effect on age trajectory of heroin use

The dynorphin/kappa opioid receptor (Dyn/KOR) system is involved in reward processing and dysphoria/anhedonia. Exposure to mu-opioid receptor agonists such as heroin increases expression of the prodynorphin gene (PDYN) in the brain. In this study in a Caucasian cohort, we examined the association of the functional PDYN 68-bp repeat polymorphism with opioid use disorders. In this case-control study, 554 subjects with Caucasian ancestry (142 healthy controls, 153 opioid-exposed, but never opioid dependent, NOD, and 259 with an opioid dependence diagnosis, OD) were examined for association of the PDYN 68-bp repeats with the diagnosis of opioid dependence (DSM-IV criteria), with a dimensional measure of heroin exposure (KMSK scale), and age trajectory parameters of heroin use (age of heroin first use, and age of onset of heaviest use). The PDYN 68-bp repeat genotype (classified as: "short-short" [SS], "long-long" [LL], and "short-long" [SL], based on the number of repeats) was not associated with categorical opioid dependence diagnoses. However, the LL genotype was associated with later age of first heroin use than the SS + SL genotype (19 versus 18 years; p < 0.01). This was also confirmed by a significant positive correlation between the number of repeats and the age of first use of heroin, in volunteers with OD (Spearman r = 0.16; p = 0.01). This suggests that the functional PDYN 68-bp repeat genotype is associated with the age of first use of heroin in Caucasians diagnosed with opioid dependence.

We Can't Go Cold Turkey: Why Suppressing Drug Markets Endangers Society

This essay argues that policies aimed at suppressing drug use exacerbate the nation's opioid problem. It neither endorses drug use nor advocates legalizing the consumption and sale of all substances in all circumstances. Instead, it contends that trying to suppress drug markets is the wrong goal, and in the midst of an addiction crisis it can be deadly. There is no single, correct drug policy; the right approach depends crucially on the substance at issue, the patterns of use and supply, and the jurisdiction's culture, institutions, and material resources. Decriminalization is no panacea for a nation's drug problems. Nevertheless, either de jure or de facto decriminalization of personal drug possession is a necessary condition for mitigating this crisis.

Dopamine gene variants in opioid addiction: comparison of dependent patients, nondependent users and healthy controls

AIM

To determine whether specific dopaminergic system gene variants are associated with opioid dependence.

PATIENTS & METHODS

Subjects included 153 healthy controls, 163 opioid exposed, but not dependent and 281 opioid dependent. Genotypes of 90 variants in 13 genes were examined.

RESULTS

The most significant results were obtained for DA β-hydroxylase variants, rs2073837 and rs1611131, which were associated with protection from addiction (q = 0.0172, 0.0415, respectively) and the functional TH variant, rs2070762, was associated with more risk (q = 0.0387). The three variants also showed a combined effect that remained significant after correction for multiple testing (p_final = 0.0039).

CONCLUSION

These data offer support that dopaminergic gene variants have a role in opioid dependence and warrant further study.

Telling our stories: heroin-assisted treatment and SNAP activism in the Downtown Eastside of Vancouver

Background

This article highlights the experiences of a peer-run group, SALOME/NAOMI Association of Patients (SNAP), that meets weekly in the Downtown Eastside of Vancouver, British Columbia, Canada. SNAP is a unique independent peer- run drug user group that formed in 2011 following Canada’s first heroin-assisted treatment trial (HAT), North America Opiate Medication Initiative (NAOMI). SNAP’s members are now made up of former research participants who participated in two heroin-assisted trials in Vancouver. This article highlights SNAP members’ experiences as research subjects in Canada’s second clinical trial conducted in Vancouver, Study to Assess Longer-term Opioid Medication Effectiveness (SALOME), that began recruitment of research participants in 2011.

Methods

This paper draws on one brainstorming session, three focus groups, and field notes, with the SALOME/NAOMI Association of Patients (SNAP) in late 2013 about their experiences as research subjects in Canada’s second clinical trial, SALOME in the DTES of Vancouver, and fieldwork from a 6-year period (March 2011 to February 2017) with SNAP members. SNAP’s research draws on research principles developed by drug user groups and critical methodological frameworks on community-based research for social justice.

Results

The results illuminate how participating in the SALOME clinical trial impacted the lives of SNAP members. In addition, the findings reveal how SNAP member’s advocacy for HAT impacts the group in positive ways. Seven major themes emerged from the analysis of the brainstorming and focus groups: life prior to SALOME, the clinic setting and routine, stability, 6-month transition, support, exiting the trial and ethics, and collective action, including their participation in a constitutional challenge in the Supreme Court of BC to continue receiving HAT once the SALOME trial ended.

Conclusions

HAT benefits SNAP members. They argue that permanent HAT programs should be established in Canada because they are an effective harm reduction initiative, one that also reduces opioid overdose deaths.

Acceptability of Extended-Release Naltrexone by Heroin-Dependent Patients and Addiction Treatment Providers in the Netherlands

BACKGROUND

Extended-release naltrexone (XRNT) was developed to overcome poor treatment compliance with oral naltrexone in alcohol and opioid-dependent patients. XRNT injections are registered in the United States and Russia, but not in The Netherlands. However, XRNT can be obtained for individual patients, but it is expensive and not reimbursed by the health insurance.

OBJECTIVES

This study evaluates the support for abstinence oriented treatment among heroin-dependent patients and the acceptability of XRNT injections by heroin-dependent patients and treatment providers in The Netherlands.

METHODS

A sample of 261 patients in methadone maintenance treatment or heroin assisted treatment and a sample of 188 addiction treatment providers completed specially designed questionnaires.

RESULTS

The current study shows that many patients in opioid maintenance treatment (58%) report a desire to become abstinent from opioids and that 83% of the patients with a desire for abstinence are interested in XRNT. The majority of treatment providers (81%) are willing to support the prescription of XRNT injections in opioid-dependent patients to prevent relapse after detoxification.

CONCLUSIONS

The current practice of automatic and indefinite continuation of opioid substitution should therefore be reconsidered. However, XRNT injections are very expensive and currently not reimbursed by the health insurance agencies in The Netherlands and thus not really available to most patients.

Variants of opioid system genes are associated with non-dependent opioid use and heroin dependence

BACKGROUND

Heroin addiction is a chronic, relapsing brain disease. Genetic factors are involved in the development of drug addiction. The aim of this study was to determine whether specific variants in genes of the opioid system are associated with non-dependent opioid use and heroin dependence.

METHODS

Genetic information from four subject groups was collected: non-dependent opioid users (NOD) [n=163]; opioid-dependent (OD) patients in methadone maintenance treatment (MMT) [n=143]; opioid-dependent MMT-resistant patients in heroin-assisted treatment (HAT) [n=138]; and healthy controls with no history of opioid use (HC) [n=153]. Eighty-two variants in eight opioid system genes were studied. To establish the role of these genes in (a) non-dependent opioid use, and (b) heroin dependence, the following groups were compared: HC vs. NOD; HC vs. OD (MMT+HAT); and NOD vs. OD (MMT+HAT).

RESULTS

Five unique SNPs in four genes showed nominally significant associations with non-dependent opioid use and heroin dependence. The association of the delta opioid receptor (OPRD1) intronic SNP rs2236861 with non-dependent opioid use (HC vs. NOD) remained significant after correction for multiple testing (OR=0.032; p_corrected=0.015). This SNP exhibited a significant gene-gene interaction with prepronociceptin (PNOC) SNP rs2722897 (OR=5.24; p_corrected=0.041) (HC vs. NOD).

CONCLUSIONS

This study identifies several new and some previously reported associations of variants with heroin dependence and with non-dependent opioid use, an important and difficult to obtain group not extensively studied previously. Further studies are warranted to confirm and elucidate the potential roles of these variants in the vulnerability to illicit drug use and drug addiction.

Efficacy of cocaine contingency management in heroin-assisted treatment: Results of a randomized controlled trial

AIMS

To determine the efficacy of contingency management (CM), targeting cocaine use, as an add-on intervention for heroin dependent patients in supervised heroin-assisted treatment (HAT) with frequent cocaine use.

DESIGN

Multi-center, open-label, parallel group, randomized controlled trial.

SETTING

Twelve specialized addiction treatment centers for HAT in The Netherlands; April 2006-January 2011.

PARTICIPANTS

214 chronic, treatment-refractory heroin dependent patients in HAT, with frequent cocaine use.

INTERVENTIONS

Routine, daily supervised diacetylmorphine treatment, co-prescribed with oral methadone (HAT), with and without 6 months contingency management for cocaine use as an add-on intervention; HAT+CM and HAT-only, respectively.

MEASUREMENTS

Primary outcome was the longest, uninterrupted duration of cocaine abstinence, based upon laboratory urinalysis. Secondary outcome measures included other cocaine-related measures, treatment retention in HAT, and multi-domain health-related treatment response.

FINDINGS

In an intention-to-treat analysis, HAT+CM was more effective than HAT-only in promoting longer, uninterrupted duration of cocaine abstinence (3.7 weeks versus 1.6 weeks; negative binomial regression: Exp(B)=2.34, 95%-CI: 1.70-3.23; p<0.001). This result remained significant in sensitivity analyses and was supported by all secondary, cocaine-related outcome measures. Treatment retention in HAT was high (91.6%) with no difference between the groups. The improvement in multi-domain health-related treatment response during the trial was numerically higher in HAT+CM (from 37.4% to 53.1%; +15.7%) than in HAT-only (from 44.5% to 46.5%; +2.0%), but this difference was statistically not significant.

CONCLUSIONS

Contingency management is an effective add-on intervention to promote longer, uninterrupted periods of cocaine abstinence in chronic, treatment-refractory heroin dependent patients in heroin-assisted treatment with frequent cocaine use. The trial has been registered in The Netherlands National Trial Register under clinical trial registration number NTR4728.

Un Jalón, Un Volteón, y Otra Vez: High-Risk Crack Smoking Paraphernalia in México City

During the past decade, crack smoking has increased in Mexico among poor urban populations. Despite this increasing prevalence, little is known about the types of paraphernalia used and related sharing practices and physical harms. Data come from in-depth semi-structured interviews and observations with 156 current crack smokers in Mexico City. Findings reveal a complex, crack-smoking process in Mexico City that represents an interconnected structure of paraphernalia items and pipes that could contribute to detrimental health consequences. Specifically, we identify essential paraphernalia items that make the smoking of crack possible; describe the homemade construction of two categories of pipes; and detail the sharing practices and physical harms associated with these paraphernalia. Results point towards a smoking process that is embedded in impoverished urban neighborhoods sustained by an accessible street-level crack market. Discussed are the policy and intervention implications associated with reducing crack-related health consequences in Mexico and other Latin American countries.

Treating Addictions: Harm Reduction in Clinical Care and Prevention

This paper examines the role of clinical practitioners and clinical researchers internationally in establishing the utility of harm-reduction approaches to substance use. It thus illustrates the potential for clinicians to play a pivotal role in health promoting structural interventions based on harm-reduction goals and public health models. Popular media images of drug use as uniformly damaging, and abstinence as the only acceptable goal of treatment, threaten to distort clinical care away from a basis in evidence, which shows that some ways of using drugs are far more harmful than others and that punitive approaches and insistence on total abstinence as the only goal of treatment often increases the harms of drug use rather than reducing drug use. Therefore the leadership and scientific authority of clinicians who understand the health impact of harm-reduction strategies is needed. Through a review of harm-reduction interventions in Canada, the United Kingdom, the United States, Australia, Switzerland, and the Netherlands, we identify three ways that clinicians have helped to achieve a paradigm shift from punitive approaches to harm-reduction principles in clinical care and in drug policy: (1) through clinical research to provide data establishing the effectiveness and feasibility of harm-reduction approaches, (2) by developing innovative clinical programmes that employ harm reduction, and thereby (3) changing the standard of care to include routine use of these evidence-based (but often misunderstood) approaches in their practices. We argue that through promotion of harm-reduction goals and methods, clinicians have unique opportunities to improve the health outcomes of vulnerable populations.

Sustained-release dexamfetamine in the treatment of chronic cocaine-dependent patients on heroin-assisted treatment: a randomised, double-blind, placebo-controlled trial

BACKGROUND

Heroin-assisted treatment is effective for methadone treatment-refractory heroin-dependent patients, but continued comorbid cocaine dependence remains problematic. Sustained-release dexamfetamine is a promising agonist pharmacotherapy for cocaine dependence and we aimed to assess its acceptance, efficacy, and safety.

METHODS

In this multicentre, randomised, double-blind, placebo-controlled trial, patients who were treatment-refractory, as indicated by at least two earlier failed treatments aimed at reducing or abstaining from cocaine use, and who regularly (≥8 days/month) used crack-cocaine were enrolled from four heroin-assisted treatment centres in the Netherlands. Eligible patients were randomly assigned (1:1) to receive either 12 weeks of daily, supervised prescription of 60 mg/day oral sustained-release dexamfetamine or placebo in addition to co-prescribed methadone and diacetylmorphine. Randomisation was done by the collaborating pharmacist, using a computer-generated random number sequence with stratification by treatment centre in blocks of four per stratum. Randomisation was masked to patients, staff, and researchers throughout the study. The primary outcome was the number of self-reported days of cocaine use during study treatment, assessed every 4 weeks. Primary and safety analyses were done in the intention-to-treat population. The study was registered with the European Union Drug Regulating Authorities Clinical Trials (EUdraCT 2013-004024-11) and with The Netherlands Trial Register (NTR2576).

FINDINGS

Between Aug 8, 2014, and Feb 27, 2015, 111 patients were assessed for eligibility, of whom 73 were enrolled and randomised; 38 patients were assigned to the sustained-release dexamfetamine group and 35 to the placebo group. Sustained-release dexamfetamine treatment resulted in significantly fewer days of cocaine use than placebo treatment (mean 44·9 days [SD 29·4] vs 60·6 days [24·3], respectively [95% CI of difference 3·1-28·4]; p=0·031; Cohen's standardised effect size d=0·58). One or more adverse events were reported by 28 (74%) patients in the dexamfetamine group and by 16 (46%) patients in the placebo group. Most adverse events were transient and well-tolerated.

INTERPRETATION

Sustained-release dexamfetamine is a well accepted, effective, and safe agonist pharmacotherapy for comorbid treatment-refractory cocaine dependence in heroin-dependent patients in heroin-assisted treatment. Future research should aim to replicate these findings in chronic cocaine-dependent and other stimulant-dependent patients in more routine treatment settings, including strategies to optimise treatment adherence like medication management interventions and contingency management.

FUNDING

Netherlands Organisation for Health Research and Development.

Opioid substitution therapy: Lowering the treatment thresholds

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Heroin on trial: systematic review and meta-analysis of randomised trials of diamorphine-prescribing as treatment for refractory heroin addiction†

BACKGROUND

Supervised injectable heroin (SIH) treatment has emerged over the past 15 years as an intensive treatment for entrenched heroin users who have not responded to standard treatments such as oral methadone maintenance treatment (MMT) or residential rehabilitation.

AIMS

To synthesise published findings for treatment with SIH for refractory heroin-dependence through systematic review and meta-analysis, and to examine the political and scientific response to these findings.

METHOD

Randomised controlled trials (RCTs) of SIH treatment were identified through database searching, and random effects pooled efficacy was estimated for SIH treatment. Methodological quality was assessed according to criteria set out by the Cochrane Collaboration.

RESULTS

Six RCTs met the inclusion criteria for analysis. Across the trials, SIH treatment improved treatment outcome, i.e. greater reduction in the use of illicit 'street' heroin in patients receiving SIH treatment compared with control groups (most often receiving MMT).

CONCLUSIONS

SIH is found to be an effective way of treating heroin dependence refractory to standard treatment. SIH may be less safe than MMT and therefore requires more clinical attention to manage greater safety issues. This intensive intervention is for a patient population previously considered unresponsive to treatment. Inclusion of this low-volume, high-intensity treatment can now improve the impact of comprehensive healthcare provision.

The SALOME study: recruitment experiences in a clinical trial offering injectable diacetylmorphine and hydromorphone for opioid dependency

BACKGROUND

The Study to Assess Long-term Opioid Medication Effectiveness (SALOME) is a two-stage phase III, single site (Vancouver, Canada), randomized, double blind controlled trial designed to test if hydromorphone is as effective as diacetylmorphine for the treatment of long-term illicit opioid injection. Recruiting participants for clinical trials continues to be a challenge in medical and addiction research, with many studies not being able to reach the planned sample size in a timely manner. The aim of this study is to describe the recruitment strategies in SALOME, which offered appealing treatments but had limited clinic capacity and no guaranteed post-trial continuation of the treatments.

METHODS

SALOME included chronic opioid-dependent, current illicit injection opioid users who had at least one previous episode of opioid maintenance treatment. Regulatory approvals were received in June 2011 and recruitment strategies were implemented over the next 5 months. Recruitment strategies included ongoing open communication with the community, a consistent and accessible team and participant-centered screening. All applicants completed a pre-screening checklist to assess prerequisites. Applicants meeting these prerequisites were later contacted to commence the screening process.

RESULTS

A total of 598 applications were received over the two-year recruitment period; 130 were received on the first day of recruitment. Of these applicants, 485 met prerequisites; however, many could not be found or were not reached before recruitment ended. For the 253 candidates who initiated the screening process, the average time lapse between application and screening date was 8.3 months (standard deviation [SD] = 4.44) and for the 202 randomized to the study, the average processing time from initial screen to randomization was 25.9 days (SD = 37.48; Median = 15.0).

CONCLUSIONS

As in prior trials offering injectable diacetylmorphine within a supervised model, recruiting participants for this study took longer than planned. The recruitment challenges overcome in SALOME were due to the high number of applicants compared with the limited number that could be randomized and treated. Our study emphasizes the value of integrating these strategies into clinical addiction research to overcome study-specific barriers.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01447212.

Criminal involvement and crime specialization among crack users in the Netherlands

BACKGROUND/AIMS

Crack users in the Netherlands are an ageing and diverse population with longstanding criminal careers. Our aim was to assess factors associated with current criminal involvement and specialization in selling drugs, property crime and violence.

METHOD

A sample of 1,039 frequent crack users was recruited in three major Dutch cities, combining respondent-driven sampling with random institutional sampling. Bivariate and logistic regression analyses were performed to find factors associated with current criminality.

RESULTS

A total of 431 participants (41.5%) had engaged in crime in the past 30 days, mostly selling drugs (68.9%), followed by property crimes (34.4%) and a few cases of violent crime (9.7%). Younger age, homelessness, heavier patterns of use and a more prolific criminal justice history were associated with current criminality. Those receiving welfare benefits tended to be more likely to specialize only in selling drugs as opposed to (also) property crimes.

CONCLUSION

Reducing drug use among criminally involved crack users and addressing their housing conditions could have a significant impact on reducing drug-related crime. Welfare benefits might act as protective factor against committing property crimes but not against the selling of drugs.

Personality as a risk factor for illicit opioid use and a protective factor for illicit opioid dependence

BACKGROUND

Most studies investigating the role of personality as a risk factor for the development of opioid dependence compare dependent opioid users with healthy controls who never used heroin. In order to understand the potential protective role of personality, it is crucial to compare illicit opioid users who never became dependent with dependent opioid users.

AIMS

This study aims to examine the role of personality as a risk factor for opioid use and as a protective factor for the development of opioid dependence.

METHODS

Comparing personality factors between three groups: (1) 161 never-dependent illicit opioid users who have been using illicit opioids but never became opioid dependent; (2) 402 dependent opioid users in methadone maintenance treatment or heroin-assisted treatment; and (3) 135 healthy controls who never used heroin. Personality was assessed with a short version of Cloninger's Temperament and Character Inventory.

RESULTS

Never-dependent opioid users reported more Novelty Seeking and Harm Avoidance and less Self-Directedness and Cooperativeness than healthy controls and more Reward Dependence and Self-Directedness, and less Harm Avoidance than dependent opioid users. Furthermore, never-dependent opioid users reported more Self-Transcendence than both dependent opioid users and healthy controls.

CONCLUSIONS

Never-dependent opioid users may have started to use opioids partly due to their tendency to seek novel and/or spiritual experiences (high Novelty Seeking, high Self-Transcendence) and their tendency to avoid aversive stimuli (high Harm Avoidance), whereas they may have been protected against the development of dependence by their need for social approval (high Reward Dependence) and their self-efficacy (high Self-Directedness).

A chance to stop and breathe: participants' experiences in the North American Opiate Medication Initiative clinical trial

Background

The North American Opiate Medication Initiative (NAOMI) clinical trial compared the effectiveness of injectable diacetylmorphine (DAM) or hydromorphone (HDM) to oral methadone maintenance treatment (MMT). This study aimed to determine participants’ perceptions of treatment delivered in NAOMI.

Methods

A qualitative sub-study was conducted with 29 participants (12 female): 18 (62.1%) received injectable DAM or HDM and 11 (37.9%) received MMT. A phenomenological theoretical framework was used. Semi-structured interviews were audio-recorded and transcribed verbatim. A thematic analysis was used over successive phases and was driven by the semantic meanings of the data.

Results

Participants receiving injectable medications suggested that the supervised delivery model was stringent but provided valuable stability to their lives. Females discussed the adjustment required for the clinical setting, while males focused on the challenging clinic schedule and its impact on employment abilities. Participants receiving MMT described disappointment with being randomized to this treatment; however, positive aspects, including the quick titration time and availability of auxiliary services, were also discussed.

Conclusion

Treatment with injectable DAM (or HDM) is preferred by participants and considered effective in reducing the burden of opioid dependency. Engaging patients in research regarding their perceptions of treatment provides a comprehensive assessment of treatment needs and barriers.

Clinical trial registration

NCT00175357

HIV infection among people who inject drugs: the challenge of racial/ethnic disparities

Racial/ethnic disparities in HIV infection, with minority groups typically having higher rates of infection, are a formidable public health challenge. In the United States, among both men and women who inject drugs, HIV infection rates are elevated among Hispanics and non-Hispanic Blacks. A meta-analysis of international research concluded that among persons who inject drugs, racial and ethnic minorities were twice as likely to acquire an HIV infection, though there was great variation across the individual studies. To examine strategies to reduce racial/ethnic disparities among persons who inject drugs, we reviewed studies on injection drug use and its role in HIV transmission. We identified four sets of evidence-based interventions that may reduce racial/ethnic disparities among persons who inject drugs: HIV counseling and testing, risk reduction services, access to antiretroviral therapy, and drug abuse treatment. Implementation of these services, however, is insufficient in many countries, including the United States. Persons who inject drugs appear to be changing drug use norms and rituals to reduce their risks. The challenges are to (a) develop a validated model of how racial/ethnic disparities in HIV infection arise, persist, and are reduced or eliminated over time and (b) implement evidence-based services on a sufficient scale to eliminate HIV transmission among all persons who inject drugs.

Yet they failed to do so: recommendations based on the experiences of NAOMI research survivors and a call for action

BACKGROUND

This article highlights the experiences of a unique group. In January 2011, Dave Murray organized a group of participants from the North American Opiate Medication Initiative (NAOMI) heroin-assisted treatment clinical trials from 2005 to 2008 in the Downtown Eastside of Vancouver (DTES), B.C., Canada. The NAOMI Patients Association (NPA) is an independent group that currently meets every Saturday in the DTES. Currently, all members of the NPA are former participants in the heroin stream of the clinical trial. The NPA offers support, education, and advocacy to its members.

METHODS

Drawing on brainstorming sessions and focus groups that were conducted in the summer of 2011, this paper highlights the experiences of NPA members in their own words.

RESULTS

The findings provide a lens to understand how becoming a research subject for the NAOMI trial impacted the lives of NPA members, both positive and negative. The NPA members discuss ethics, consent, recommendations for future HAT programs and studies, and ongoing advocacy.

Craving and illicit heroin use among patients in heroin-assisted treatment

AIMS

To investigate in heroin-assisted treatment (HAT) compared to methadone maintenance treatment (MMT): the course of heroin craving and illicit heroin use, their mutual association, and their association with multi-domain treatment response.

DESIGN

RCTs on the efficacy of 12 months co-prescribed injectable or inhalable HAT compared to 12 months continued oral MMT.

SETTING

Outpatient treatment in MMT- or specialized HAT-centers in the Netherlands.

PARTICIPANTS

Chronic, treatment-refractory heroin dependent patients (n=73). STUDY PARAMETERS: General craving for heroin (Obsessive Compulsive Drug Use Scale); self-reported illicit heroin use; multi-domain treatment response in physical, mental and social health and illicit drug use.

FINDINGS

The course of heroin craving and illicit heroin use differed significantly, with strong reductions in HAT but not in MMT. General heroin craving was significantly related to illicit heroin use. Heroin craving was not and illicit heroin use was marginally related to multi-domain treatment response, but only in MMT and not in HAT.

CONCLUSIONS

Heroin craving and illicit heroin use were significantly associated and both strongly decreased in HAT but not in MMT. Craving was not related to multi-domain treatment response and illicit heroin use was marginally related to treatment response in MMT, but not in HAT. The latter was probably due to the strong reduction in illicit heroin use in most patients in HAT and the small sample size of the sub-study. It is hypothesized that the strong reductions in craving for heroin in HAT are related to the stable availability of prescribed, pharmaceutical grade heroin.

Refined sewer epidemiology mass balances and their application to heroin, cocaine and ecstasy

The detection of illicit drugs in environmental matrices may be a cause for concern, both from the perspective of their potential environmental impacts and the fact that their presence in detectable concentrations would be an indicator of significant drug use. The primary goal behind recent studies on this subject has been to use measured influent concentrations of selected illicit drugs or their in vivo metabolites in the environment as a means of estimating the abuse level of these drugs and patterns of consumption. Thus-far, such calculations have hinged on the use of solitary excretion estimates from single studies of limited scope and/or studies of limited applicability. Therefore, the need exists to conduct a comprehensive meta-analysis of metabolic disposition studies to construct excretions profiles for the various illicit drugs and their in vivo metabolites. The constructed excretory profiles should not only provide mean excretion values but also indicate the expected variations in excreted fractions that arise due to differences not only in the metabolic capacity of users but also in the efficiencies of various routes of administration for a given illicit drug. Therefore, the primary goal of the research presented here was to refine sewer epidemiology extrapolation mass balances for various illicit drugs of interest by constructing their excretory profiles segregated by route-of-administration. After conducting such a study with a multi-national scope on illicit drugs including cocaine, heroin and ecstasy, the results obtained clearly indicate that extrapolation factors currently being used in literature for these drugs to enumerate prevalence of abuse required significant refinement to increase their reliability.