Severity of substance abuse and psychiatric problems among perinatal drug-dependent women

Comparing methadone and buprenorphine maintenance with methadone-assisted withdrawal for the treatment of opioid dependence during pregnancy: maternal and neonatal outcomes

Pregnancy can motivate opioid-dependent women to seek substance abuse treatment. Research has demonstrated that although prenatal exposure to buprenorphine results in less severe neonatal abstinence syndrome (NAS) relative to prenatal methadone exposure, the maternal and other neonatal outcomes are similar for the two medications. Maternal and neonatal outcomes for opioid-dependent pregnant women receiving these medications have not been systematically ompared with methadone-assisted withdrawal. The present study provides an initial assessment of the relative efficacy of both methadone and buprenorphine maintenance versus methadone-assisted withdrawal in terms of neonatal and maternal delivery outcomes. Data were derived from (1) the MOTHER (Maternal Opioid Treatment: Human Experimental Research) study at the Johns Hopkins University Bayview Medical Center (JHBMC), or (2) retrospective records review of women who underwent methadone-assisted withdrawal at the JHBMC during the time period in which participants were enrolled in the MOTHER study. Compared with the methadone maintenance group, the methadone-assisted withdrawal group had a significantly lower mean NAS peak score (Means = 13.7 vs 7.0; P = 0.002), required a significantly lower mean amount of morphine to treat NAS (Means = 82.8 vs 0.2; P < 0.001), had significantly fewer days medicated for NAS (Means = 31.5 vs 3.9; P < 0.001), and remained in the hospital for a significantly fewer number of days, on average (Means = 24.2 vs 7.0; P < 0.019). Compared with the buprenorphine maintenance group, the methadone-assisted withdrawal group required a significantly lower mean amount of morphine to treat NAS (Means = 8.2 vs 0.2; P < 0.001) and significantly fewer days medicated for NAS (Means = 12.0 vs 3.9; P = 0.008). Findings suggest that it is possible for some opioid-dependent pregnant women to succeed with methadone-assisted withdrawal. Future research needs to more fully evaluate the potential benefits and risks of methadone-assisted withdrawal for the maternal-fetal dyad.

Smoking prevalence in addiction treatment: a review

INTRODUCTION

This review explores whether smoking prevalence in addiction treatment samples exceeds that shown in epidemiological data for persons with alcohol or other drug use disorders and whether smoking may have decreased over time in the addiction treatment population as it has done in the general population.

METHODS

English language papers published between 1987 and 2009 were searched electronically. Forty papers reporting smoking prevalence for addiction treatment samples in the United States were identified, and key predictor variables were abstracted. Random logistic models were used to assess relationships between each individual predictor (year, treatment modality, primary drug treated, government status, and public/private funding status) and smoking prevalence.

RESULTS

The lowest smoking prevalence aggregated for studies reported in any single year was 65%, well above epidemiological estimates reported among those with alcohol use and drug use disorders. The odds of smoking were higher in methadone maintenance programs (odds ratio [OR] = 2.25, CI = 1.08, 4.68) as compared with outpatient programs. No other variables in the model were significant. Reanalysis omitting recent studies that may represent outliers or confounding with type of treatment showed a small but significant decrease in smoking over time (OR = 0.9891, CI = 0.9888, 0.9893).

CONCLUSIONS

The very high smoking rates reported in addiction treatment samples warrant significant, organized, and systemic response from addiction treatment systems, from agencies that fund and regulate those systems, and from agencies concerned with tobacco control.

Reinforcement-based treatment improves the maternal treatment and neonatal outcomes of pregnant patients enrolled in comprehensive care treatment

This randomized clinical trial examined the efficacy of comprehensive usual care (UC) alone (n = 42) or enhanced by reinforcement-based treatment (RBT) (n = 47) to produce improved treatment outcomes, maternal delivery, and neonatal outcomes in pregnant women with opioid and/or cocaine substance use disorders. RBT participants spent, on average, 32.6 days longer in treatment (p < .001) and almost six times longer in recovery housing than did UC participants (p = .01). There were no significant differences between the RBT and UC conditions in proportion of participants testing positive for any illegal substance. Neonates in the RBT condition spent 1.3 fewer days hospitalized after birth than UC condition neonates (p = .03), although the two conditions did not differ significantly in neonatal gestational age at delivery, birth weight, or number of days hospitalized. Integrating RBT into a rich array of comprehensive care treatment components may be a promising approach to increase maternal treatment retention and reduce neonatal length of hospital stay.

Relationship between cigarette use and mood/anxiety disorders among pregnant methadone-maintained patients

This study investigates the association between cigarette use and current mood/anxiety disorders among pregnant opioid-dependent patients. Pregnant methadone-maintained women (N = 122) completed the Addiction Severity Index and Structured Clinical Interview for DSM-IV. Participants were categorized based on past 30 days cigarette use: no (n = 15) and any smoking (n = 107); this latter group was then subdivided into light (one to ten cigarettes/day; n = 55), and heavy smokers (11+ cigarettes/day; n = 52). Any smoking was significantly associated with any current mood/anxiety disorder (p < 0.001), any current mood disorder (p = 0.007), and any current anxiety disorder (p < 0.001). No significant association was found between specific level of cigarette use and mood/anxiety disorders. This association between smoking and psychiatric disorders has implications for the mental and physical health of methadone-maintained women and their children, and may contribute to the understanding of the physiological mechanisms underlying smoking and nicotine dependence.

Factors mediating and moderating the relationship between gender and utilization of health care among Puerto Rican drug users in New York

This study examined factors that mediate and moderate the relationship between gender and utilization of mental health and medical services in the past year among Puerto Rican drug users (308 females; 892 males) recruited in New York City. Experience of sexual or physical abuse, injection drug use, relationship variables (e.g., having a sexual partner who is an injection drug user), and serious or chronic mental/medical conditions were used as potential mediators and moderators. Both sexual and physical abuse mediated gender effects on use of mental health services. Having chronic medical problems mediated the relationship between gender and utilization of medical and mental health services. Significant interaction effects of gender by depression, physical abuse, and HIV sero-status on utilization of medical services were found. Health (particularly mental health) care was under-utilized by both women and men, despite high rates of depression and chronic medical conditions. The finding of under-use of medical services by HIV-positive drug users (particularly by HIV-positive women) indicates a need for further efforts to engage all HIV-positive persons in care. The findings also indicate an on-going need for mental and other health services for drug users who have been victims of abuse.

Chronic illness and multimorbidity among problem drug users: a comparative cross sectional pilot study in primary care

Background

Although multimorbidity has important implications for patient care in general practice, limited research has examined chronic illness and health service utilisation among problem drug users. This study aimed to determine chronic illness prevalence and health service utilisation among problem drug users attending primary care for methadone treatment, to compare these rates with matched 'controls' and to develop and pilot test a valid study instrument.

Methods

A cross-sectional study of patients attending three large urban general practices in Dublin, Ireland for methadone treatment was conducted, and this sample was compared with a control group matched by practice, age, gender and General Medical Services (GMS) status.

Results

Data were collected on 114 patients. Fifty-seven patients were on methadone treatment, of whom 52(91%) had at least one chronic illness (other then substance use) and 39(68%) were prescribed at least one regular medication. Frequent utilisation of primary care services and secondary care services in the previous six months was observed among patients on methadone treatment and controls, although the former had significantly higher chronic illness prevalence and primary care contact rates. The study instrument facilitated data collection that was feasible and with minimal inter-observer variation.

Conclusion

Multimorbidity is common among problem drug users attending general practice for methadone treatment. Primary care may therefore have an important role in primary and secondary prevention of chronic illnesses among this population. This study offers a feasible study instrument for further work on this issue. (238 words)

Gender differences in health status and care among HIV-infected minority drug users

Gender differences were examined in health status and HIV care among HIV-infected minority drug users. More women than men reported having HIV-related symptoms and other health conditions, such as asthma and allergies. Hepatitis B or C was more often reported by men. As compared to men, women delayed HIV care and fewer attended HIV support groups. Delayed entry into HIV treatment was also significantly related to being Hispanic and being diagnosed with HIV in the pre-HAART era. No significant gender difference was found in current use of HIV medications. Use of HIV medications was significantly related to being married, no history of childhood sexual abuse, enrollment in an HIV clinic and attending HIV support groups. The findings demonstrate the importance of family and social support for HIV-positive drug users and also suggest a need for special attention to those who have childhood sexual abuse experience.

Drug treatment disparities among Hispanic drug-using women in Puerto Rico and New York City

This paper reports findings on 334 out-of-treatment drug users in Puerto Rico and 617 in New York City, at the 6-month follow-up interview of a Longitudinal Survey. Main outcomes were health care and drug treatment utilization since baseline, assessed by asking participants if they had received physical or mental health services (including HIV medications), and if they had been in methadone maintenance, inpatient or outpatient drug treatment, or drug treatment while incarcerated. Chi-square tests were used to evaluate associations between gender and the various correlates. Logistic regression was used to calculate the contribution of each variable in predicting use of drug treatment. The analysis suggests that women in both sites were likely to suffer from disparities in both health care and drug treatment utilization when compared with men, albeit women in New York utilized more drug treatment resources and were more embedded in the immediate family than their female peers in Puerto Rico. Further research to specify the impact of contextual factors at the organizational and community levels, among members of the same ethnic group residing in different sites, may prove valuable in identifying the health needs and the factors that impede or facilitate drug-using women in obtaining the most appropriate treatment. Findings from these studies can help in developing appropriate public health policy and science-based drug treatment programs to eliminate disparities such as the ones detected in this study.