Understanding prolonged cessation from heroin use: findings from a community-based sample

The Role of Physical Exercise in Opioid Substitution Therapy: Mechanisms of Sequential Effects

It is generally accepted that chronic opioid use is associated with structural and functional changes in the human brain that lead to an enhancement of impulsive behavior for immediate satisfaction. Interestingly, in recent years, physical exercise interventions have been used as an adjunctive treatment for patients with opioid use disorders (OUDs). Indeed, exercise has positive effects on both the biological and psychosocial basis of addiction, modifying neural circuits such as the reward, inhibition, and stress systems, and thus causing behavioral changes. This review focuses on the possible mechanisms that contribute to the beneficial effects of exercise on the treatment of OUDs, with emphasis placed on the description of a sequential consolidation of these mechanisms. Exercise is thought to act initially as a factor of internal activation and self-regulation and eventually as a factor of commitment. This approach suggests a sequential (temporal) consolidation of the functions of exercise in favor of gradual disengagement from addiction. Particularly, the sequence in which the exercise-induced mechanisms are consolidated follows the pattern of internal activation-self-regulation-commitment, eventually resulting in stimulation of the endocannabinoid and endogenous opioid systems. Additionally, this is accompanied by modification of molecular and behavioral aspects of opioid addiction. Overall, the neurobiological actions of exercise in combination with certain psychological mechanisms appear to promote its beneficial effects. Given the positive effects of exercise on both physical and mental health, exercise prescription is recommended as a complement to conventional therapy for patients on opioid maintenance treatment.

Socioeconomic stability is associated with lower injection frequency among people with distinct trajectories of injection drug use

BACKGROUND

Little is known about how socioeconomic circumstances relate to injection frequencies among people who inject drugs (PWID) with diverse trajectories of injection. We aimed to characterize trajectories of injection drug use in a community-based sample of PWID over 7.5 years and to investigate the extent to which two modifiable factors reflecting socioeconomic stability-stable housing and stable income-relate to injection frequencies across distinct trajectories.

METHODS

HEPCO is an open, prospective cohort study of PWID living in Montréal with repeated follow-up at three-month or one-year intervals. Self-reported data on injection frequency, housing and income are collected at each visit. Injection frequency was defined as the number of injection days (0-30), reported for each of the past three months. Using group-based trajectory modeling, we first estimated average trajectories of injection frequency. Then, we estimated the trajectory group-specific average shift upward or downward associated with periods of stable housing and stable income relative to periods when these conditions were unstable.

RESULTS

Based on 19,527 injection frequency observations accrued by 529 participants followed over 2011-2019 (18.3% female, median age: 41), we identified five trajectories of injection frequency: three characterized by sustained injection at different frequencies (28% infrequent; 19% fluctuating; 19% frequent), one by a gradual decline (12%), and another by cessation (28%). Periods of stable housing and stable income were each independently associated with a lower injection frequency, on average, in all five trajectory groups (2.2-7.5 fewer injection days/month, depending on the factor and trajectory group).

CONCLUSION

Trajectories of injection drug use frequency were diverse and long-lasting for many PWID. Despite this diversity, socioeconomic stability was consistently associated with a lower injection frequency, emphasizing the close relationship between access to fundamental necessities and injection patterns in all PWID, irrespective of whether they are on a path to cessation or sustained injecting.

Sustained Sobriety: A Qualitative Study of Persons with HIV and Chronic Hepatitis C Coinfection and a History of Problematic Drinking

For persons diagnosed with HIV and who are coinfected with hepatitis C virus (HCV), chronic liver disease is a leading cause of death and excessive consumption of alcohol can be a contributing factor. Little is known about the factors these individuals identify as key to achieving sustained sobriety. In this qualitative study, fourteen HIV/HCV coinfected persons who endorsed past problematic drinking were interviewed about their path to sustained sobriety. In open-ended interviews, participants often described their drinking in the context of polysubstance use and their decision to become sober as a singular response to a transcendent moment or a traumatic event. All articulated specific, concrete strategies for maintaining sobriety. The perceived effect of the HIV or HCV diagnosis on sobriety was inconsistent, and medical care as an influence on sobriety was rarely mentioned. Qualitative interviews may offer new insights on interventions and support strategies for heavy-drinking persons with HIV/HCV coinfection.

Overcoming Heroin Addiction without the Use of Pharmaceuticals: A Qualitative Interview Study

Although opioid maintenance treatment lowers mortality and has proven efficacy in reducing opioid use, it is not an option for every person with an opioid addiction. Studies of the experiences of those who have overcome their addiction without pharmaceuticals are rare, but vital to understanding the quitting process and how it can be facilitated. This study investigated what persons with a previous heroin addiction perceived as helpful when overcoming their addiction without the use of pharmaceuticals, and what they consider important for health services to consider. Eleven adults with former heroin addiction participated. Most described the leaving process as prolonged and including many attempts. Experiences such as being worn out and numb, life-threatening overdoses, personal losses or a growing feeling of missing important stages in life fueled the decision process. Envisioning a future without drugs was described as an important component. To maintain the decision to refrain from heroin use the possibility to gain a new social context was crucial. Results imply that health care professionals should be proactive by seizing the moment of opportunity for change (e.g., after an overdose), and should be empathetic and never give up on a person. Those concerned with care, welfare and other support or control systems in society must cooperate to offer more personalized support.

Incidence and predictors of drug overdoses among a cohort of >10,000 patients treated for substance use disorder

BACKGROUND

Drug overdoses remain a significant public health burden throughout the world. This study assessed the incidence and predictors of non-fatal and fatal drug overdoses among patients with an opioid use, treated for drug use disorders (DUD) at public treatment centers in Denmark.

METHODS

A consecutive cohort of patients (n = 11,199) were tracked from date of first registered enrollment between the year 2000 and 2010 to first registered drug overdose, death or December 31st 2010, whichever occurred first. Competing-risks regression models were fitted to estimate the sub hazard ratios (SHRs) of non-fatal and fatal drug overdoses and confounding risk factors.

RESULTS

A total of 3186 (28%) patients experienced a non-fatal drug overdose during follow-up, and 572 (6%) died from an overdose. Use of benzodiazepines (SHR: 1.15 95% CI 1.03, 1.28) was significantly associated with non-fatal overdose. Intravenous drug use and previous hospitalization for a non-fatal overdose increased the risk of later non-fatal (SHR: 1.57 95% CI 1.42, 1.73) and fatal overdoses (SHR: 1.43 95% CI 1.12, 1.82).

CONCLUSIONS

Patients who use opioids remain at risk of overdoses for a long time after discharge from drug treatment. Besides relevant monitoring and psychosocial support in opioid maintenance treatment, there is a need for informing and educating opioid users in risk factors and preventive measures in settings where they are often difficult to access for traditional treatment services.

Aerobic Exercise Interventions for Patients in Opioid Maintenance Treatment: A Systematic Review

Background:

Opioid maintenance treatment (OMT) is the standard for treatment of opioid use disorder, but some individuals on OMT experience disrupted sleep, heightened sensitivity to pain, and continued relapse to non-medical opioid use. An adjunctive treatment that has potential to address these shortcomings of OMT is aerobic exercise.

Objective:

The aim of the present review was to identify and evaluate components of aerobic exercise interventions targeting OMT patients.

Methods:

For this PROSPERO-registered review (ID CRD42020139626), studies were identified via electronic bibliographic databases, funded research (NIH RePORTER) and clinical trials databases (ClinicalTrials.gov), and reference sections of relevant manuscripts. Studies that evaluated the effects of an aerobic exercise intervention using a comparison condition or pretest-posttest design in adult OMT patients were included.

Results:

Of 2971 unique records, three primary studies and one supplemental manuscript comprised the final sample. All studies were randomized trials involving supervised exercise interventions enrolling small samples of middle-aged OMT patients. Exercise interventions included a variety of aerobic and non-aerobic activities (e.g. flexibility exercises), and none controlled the dose of aerobic exercise. Few studies used objective measures of physical activity or cardiorespiratory fitness and there were no significant effects of adjunctive exercise on substance use outcomes, but tests of the latter were likely underpowered.

Conclusions:

Though early in the accumulation of evidence, interventions targeting aerobic exercise for OMT patients appear feasible, acceptable to patients, and beneficial. Longer-term studies that employ larger samples, include assessments of behavioral and biological mechanisms of change, more rigorous measurement of physical activity, and controlled doses of aerobic activity are warranted.

Gaining a "normal life": HIV-positive Indonesian female injection drug users in drug recovery

The number of female injection drug users in Indonesia is rapidly increasing. This study explores the experiences of women living with HIV in recovery from heroin injection. Using a ground theory approach, 22 women former drug users in Jakarta participated in this study. Six themes emerged: the challenges of quitting, the role of self-motivation, the utility of methadone treatment, the importance of partner and family support, the transformation of "self" and situation, and the rewards of a normal life if successful. These women's accounts point to the personal and cultural challenges that they faced as women, wives, and mothers.

Performance of the WHOQOL-BREF among Norwegian substance use disorder patients

BACKGROUND

Quality of life (QoL) is an established outcome measure of substance use disorder treatment. The WHOQOL-BREF is the gold standard tool, but its appropriateness for particularly vulnerable patient populations must be further explored. This article examines the scaling qualities of the WHOQOL-BREF in a Norwegian substance use disorder population, and explores relationships with social and health variables.

METHODS

107 participants in a larger national treatment study provided data during structured interviews. Item responses, responsiveness, and domain scaling qualities are reported. General linear models identified correlates of impaired QoL.

RESULTS

Three out of four domains exhibited acceptable scaling qualities, while the social relationships domain had low internal validity. 59% of the variance in physical health QoL was explained in our model by the negative main or interaction effects of depression, unemployment, social isolation, smoking, residential treatment, and weight dissatisfaction. 52% of the variance in psychological health QoL was explained by depression and being single. Depression also had significant main effects in social relationships QoL (R2 = .27) and environment QoL (R2 = .39), and social isolation and exercise had further interaction effects in environment QoL.

CONCLUSIONS

After one year in treatment, the impact of low social contact in reducing QoL, rather than specific substance use patterns, was striking. The social relationships domain is the shortest in the WHOQOL-BREF, yet social variables were important in other areas of QoL. Social support could benefit from more attention in treatment, as a lack of social support seems to be a strong risk factor for poor QoL in various domains. The WHOQOL-BREF exhibits otherwise satisfactory measurement characteristics and is an appropriate tool among this population.

Predictors of injecting cessation among a cohort of people who inject drugs in Tijuana, Mexico

INTRODUCTION

Little is known about the cessation of injecting drug use (IDU) among people who inject drugs (PWID) in low and middle-income settings, where access to effective interventions for reducing drug use (e.g., opioid substitution treatment; OST), may be limited. We measured the incidence and identified predictors of IDU cessation among a cohort of PWID in Tijuana, Mexico.

METHODS

Data were drawn from 621 participants in Proyecto El Cuete IV, a prospective cohort of PWID recruited in 2011 and interviewed biannually to 2016. A multivariable Extended Cox model was constructed to identify socio-demographic, drug use, risk environment and health-related predictors of IDU cessation (no IDU for ≥six months).

RESULTS

141 participants (23%) reported at least one IDU cessation event during follow-up. The crude IDU cessation rate was 7.3 per 100 person-years (95% Confidence Interval [CI]: 6.2-8.7). IDU cessation was negatively associated with injecting at least daily on average and heroin/methamphetamine co-injection in the past six months, and positively associated with testing HIV positive at baseline, being on methadone maintenance therapy in the past six months, and recent arrest. Concern for personal safety was also independently associated with IDU cessation.

CONCLUSIONS

The rate of IDU cessation among PWID in Tijuana was low. These findings underscore the importance of expansion of services including OST to help reduce drug use and facilitate IDU cessation for those who wish to do so. In this setting, interventions addressing individual-level economic barriers as well as broader social and structural barriers to harm reduction services are integral.

Why Do Those With Long-Term Substance Use Disorders Stop Abusing Substances? A Qualitative Study

Although a significant proportion of adults recover from substance use disorders (SUDs), little is known about how they reach this turning point or why they stop using. The purpose of the study was to explore the factors that influence reasoning and decision making about quitting substance use after a long-term SUD. Semistructured interviews were conducted with 18 participants, each of whom had been diagnosed with a SUD and had been abstinent for at least 5 years. A resource group of peer consultants in long-term recovery from SUDs contributed to the study’s planning, preparation, and initial analyses. Participants recalled harmful consequences and significant events during their years of substance use. Pressure and concern from close family members were important in their initial efforts to abstain from substance use. Being able to imagine a different life, and the awareness of existing treatment options, promoted hope and further reinforced their motivation to quit. Greater focus on why those with SUDs want to quit may help direct treatment matching; treatment completion may be more likely if the person’s reasons for seeking help are addressed.

Building abstinent networks is an important resource in improving quality of life

AIMS

To investigate changes in social network and quality of life of a substance use disorder cohort as they progressed through treatment.

DESIGN

Multi-site, prospective, observational study of 338 adults entering substance use disorder treatment.

SETTING

Patients at 21 facilities across Norway contributed baseline data when they initiated treatment, and follow-up data was collected from them one year later.

METHODS

The cohort was divided into those who completed, dropped out, and remained in treatment one year after treatment initiation. For each treatment status group, general linear models with repeated measures analyzed global and social quality of life with the generic QOL10 instrument over time. The between-group factor was a change in social network variable from the EuropASI.

FINDINGS

Those who gained an abstinent network reported the largest quality of life improvements. Improvements were smallest or negligible for the socially isolated and those who were no longer in contact with the treatment system.

CONCLUSIONS

Developing an abstinent network is particularly important to improve the quality of life of those in substance use disorder treatment. Social isolation is a risk factor for impaired quality of life throughout the treatment course.

Older Former Prisoners' Pathways to Sobriety

This study explores how older age shapes processes of substance abuse cessation among male substance users recently released from prison. Semi-structured in-depth interviews and brief surveys were conducted with 15 men aged 49+, released from prison in a large, Eastern U.S. city. A follow-up interview was conducted with each participant (n=15). Conventional content analysis was used to analyze these data. Aging was central to the stories men told about attaining and maintaining sobriety. Men gained clarity after forced detoxification in prison, which was often followed by a period of reflection and evaluation of their lives. Older age seemed integral for this period of sobriety and reflection to catalyze cognitive change, a phenomenon I term Sober Aged Reflection. Further, men described a heightened awareness of mortality that had come with older age, and were deeply afraid of dying in prison. This fear helped inspire a new commitment to sobriety and concordant rejection of the crime that had been linked with their drug use in the past. Finally, men revealed identities and goals that had changed with time, changes incompatible with on-going drug use. Policy implications are discussed.

A pilot randomized trial of exercise as adjunct therapy in a heroin-assisted treatment setting

BACKGROUND

Although the potential of exercise as an adjunct treatment for substance dependence is persuasive in theory, few controlled trials have assessed its effectiveness. Existing research has also largely focused on individuals aiming towards, or having already achieved, abstinence. This study employed a randomized design in a pilot trial to assess the feasibility, acceptance, and effects of an exercise intervention for individuals receiving outpatient heroin-assisted treatment.

METHOD

50 individuals receiving heroin-assisted treatment at a clinic in Switzerland were invited to take part in the trial. Participants were randomized to 12weeks of exercise twice per week, or a corresponding duration of non-exercise group activities in a comparison condition. Data on attendance, compliance, and numerous psychological and physiological parameters were gathered.

RESULTS

24 individuals were willing to take part in the study. 92.3% of the exercise condition (n=13) were compliant or semi-compliant with the protocol; by contrast, only 54.6% of participants in the comparison condition (n=11) were compliant or semi-compliant (χ₂=7.049; p=0.029). Participants in the exercise condition significantly increased the number of minutes spent exercising at a high intensity level (F(2,44)=3.794; p=0.046; η²=0.159). No other significant interaction effects were observed.

CONCLUSIONS

An exercise intervention is a feasible and accepted supplementary therapy to heroin-assisted treatment. Participation rates were high, particularly given the outpatient setting. No evidence regarding the potential mechanisms of exercise as a therapy modality could be identified. Patients in heroin-assisted treatment may require a longer-term exercise programme, specifically targeting particular health parameters, before measurable improvements can be observed.

Public Perspectives on Expanding Naloxone Access to Reverse Opioid Overdoses

BACKGROUND

Opioid overdoses can often be reversed with naloxone hydrochloride. Past studies on attitudes toward expanded naloxone access have surveyed drug users, family members, and providers.

OBJECTIVES

To explore how the general public perceives take-home or nonmedical first-responder access to naloxone to reverse opioid overdoses. Additionally, little is known about how support for expanded access is related to participant's endorsement of Individualism and Just World Belief-colloquially people getting what they deserve and deserving what they get.

METHODS

Lay participants completed an online survey examining concerns with and support for expanding naloxone access. Just World Belief, Individualism, and participants' dependence history were also measured. Four different hypothetical situations were considered, varying according to type of opioid (heroin versus nonmedical prescription opioid) and recipient (suburban middle class versus recent parolee).

RESULTS

Most participants agreed with at least some degree of expanded access. Analyses of variance indicated that type of opioid or recipient did not affect attitudes toward expansion. Pearson correlations and multiple regressions revealed that endorsement of Just World Beliefs and Individualism were associated with greater concerns with and less support for expansion.

IMPORTANCE

While there is general agreement with some degree of expanding naloxone access, participants' level of endorsement was influenced by their level of individualism and belief in a just world. These factors need to be considered in how to best frame messages to maximize layperson support for expansion.

The CHANGE Study: Methods and Sample Description for a Cross-Sectional Study of Heroin Cessation in New York City

The CHANGE (Cessation of Heroin: A Neighborhood Grounded Exploration) Study aimed to understand factors associated with the initiation and maintenance of sustained heroin cessation from the perspective of users themselves and specifically set out to document the correlates of natural recovery. The CHANGE Study was a case-control study conducted in New York City from 2009 to 2011. Cases were former heroin users, abstinent for 1-5 years in the past 5 years. Controls used heroin at least weekly during the past 5 years and were (1) continuous heroin users without a quit attempt of ≥2 weeks' duration or (2) relapsed heroin users who were currently using and had a quit attempt of ≥2 weeks' duration during the past 5 years. Recruitment and data collection methods are described along with limitations and a brief description of the study sample. In contrast to many studies of drug use and cessation, the CHANGE Study was designed to model success (i.e., initiation and maintenance of heroin cessation) and not failure.

Does physical activity protect against drug abuse vulnerability?

BACKGROUND

The current review examined recent literature to determine our state of knowledge about the potential ability of physical activity serve as a protectant against drug abuse vulnerability.

METHODS

Both preclinical and clinical studies were examined using either associational or random assignment study designs. In addition to examining drug use as an outcome variable, the potential neural mediators linking physical activity and drug abuse vulnerability were examined.

CONCLUSIONS

Several important conclusions may be drawn. First, the preclinical evidence is solid in showing that physical activity in various forms is able to serve as both a preventive and treatment intervention that reduces drug use, although voluntary alcohol drinking appears to be an exception to this conclusion. Second, the clinical evidence provides some evidence, albeit mixed, to suggest a beneficial effect of physical activity on tobacco dependent individuals. In contrast, there exists only circumstantial evidence that physical activity may reduce use of drugs other than nicotine, and there is essentially no solid information from random control studies to know if physical activity may prevent initiation of problem use. Finally, both preclinical and clinical evidence shows that various brain systems are altered by physical activity, with the medial prefrontal cortex (mPFC) serving as one potential node that may mediate the putative link between physical activity and drug abuse vulnerability. It is concluded that novel neurobehavioral approaches taking advantage of novel techniques for assessing the physiological impact of physical activity are needed and can be used to inform the longitudinal random control studies that will answer definitively the question posed.

Trajectories of Aging Long-Term Mexican American Heroin Injectors: The "Maturing Out" Paradox

OBJECTIVE

To examine the applicability of the "maturing out" theory to a sample of aging Mexican American men who are long-term heroin injectors.

METHOD

Ethnographic data were collected as part of a cross-sectional study of aging Mexican American heroin users in Houston with 20 current heroin users.

RESULTS

Findings indicate that dysfunctions that emerge in the heroin lifestyle lead not to cessation but rather to "maturing in," a specific process of social readjustment that returns the heroin user to a stable maintenance pattern of use instead of a recovery phase. This process of paradoxical maturing out can be attributed to the unconditional social support provided to the heroin user by family, peers, and the tecato subculture embedded in Mexican American communities.

DISCUSSION

Results highlight the implications for the intersection of heroin-related conditions, natural age-related impairments, and cognitive functioning that make this population increasingly susceptible to adverse health consequences.

The message of the heroin overdoses

Drug use can be defined as a kind of self destruction, and it is directly linked to attitudes toward death and suicide occurring in a significant number of users of different narcotics. The aim of the authors was to look for the background of this relationship between drug and death and examine the origin, development, and motives behind heroin overdose based on an analysis of previous studies. It seems clear that pure heroin overdose increased gradually over the years. The fear of the police is the inhibitory factor of the overdose prevention and notification of emergency health care service. Signs of suicide could be the own home as the chosen location for heroin overdose and the presence of partners (“moment of death companion”). Interventions should include simple techniques such as first aid, naloxone administration, resuscitation, prevention of relapse of prisoners and social network extension involving maintenance programs. Orv. Hetil., 2015, 156(9), 352–357.