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Evaluating interventions to facilitate opioid agonist treatment access among people who inject drugs in Toronto, Ontario during COVID-19 pandemic restrictions. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 104:103680. [PMID: 35447476 PMCID: PMC9005368 DOI: 10.1016/j.drugpo.2022.103680] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/22/2022] [Accepted: 03/30/2022] [Indexed: 12/01/2022]
Abstract
Background In March 2020, following a provincial COVID-19 emergency declaration, modifications to opioid agonist treatment (OAT) were introduced in Ontario, Canada to promote treatment access amid the pandemic and ongoing opioid overdose crisis. Modifications included federal exemptions to facilitate OAT prescription re-fills, extensions, and deliveries and interim treatment guidance emphasizing take-home (non-observed) doses and reduced urine drug screening for OAT patients. Methods We conducted an interrupted time series study using health administrative data from September 17th, 2019–September 21st, 2020, on 359 people who inject drugs with suspected opioid use disorder in Toronto, Ontario. We used segmented regression analyses to evaluate the joint effects of the provincial COVID-19 emergency declaration, federal OAT exemptions, and interim treatment guidance—all implemented between March 17th–23rd, 2020—on the weekly proportion of participants enrolled in OAT (i.e., ≥1 day(s) covered with methadone or buprenorphine/naloxone), with an opioid-related overdose (based on emergency department visits and hospitalizations), and who died (all-cause), and the weekly proportion of OAT-enrolled participants receiving take-home doses (i.e., ≥1 day(s) covered) and undergoing urine drug screening. Results Post-implementation, the interventions were associated with immediate absolute changes in OAT enrollment (+1.95%; 95% CI=0.04%–3.85%), receipt of take-home doses (+18.3%; 95% CI=13.2%–23.4%), and urine drug screening (-22.4%; 95% CI=[-26.9%]–[-17.9%]) and a gradual absolute increase of 0.56% in urine drug screening week-to-week (95% CI=0.27%–0.86%) beyond the pre-implementation trend. At 26 weeks post-implementation, OAT enrollment and urine drug screening approached pre-implementation levels whereas the increase in take-home doses was largely sustained (+15.0%; 95% CI=4.33%–25.6%). No post-implementation increases in opioid-related overdoses were observed. Death was not modelled (low event frequency). Conclusion Changes to OAT provision following provincial COVID-19 restrictions were associated with an immediate and sustained increase in take-home dose coverage among OAT-enrolled participants, without corresponding increases in opioid-related overdoses among all participants.
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Marks M, Scheibe A, Shelly S. High retention in an opioid agonist therapy project in Durban, South Africa: the role of best practice and social cohesion. Harm Reduct J 2020; 17:25. [PMID: 32295595 PMCID: PMC7161298 DOI: 10.1186/s12954-020-00368-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 03/26/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Moral conservatism within government and communities has resulted in a reluctance to support the provision of opioid agonist therapy for people with opioid use disorders in South Africa. In April 2017, South Africa's first low-threshold opioid agonist therapy demonstration project was launched in Durban. The project provided 54 low-income people with heroin use disorders methadone and voluntary access to psychosocial services for 18 months. At 12 months, retention was 74%, notably higher than the global average. In this paper, we aim to make sense of this outcome. METHODS Thirty semi-structured interviews, two focus groups, ten oral histories and ethnographic observations were done at various project time points. These activities explored participants' pathways into drug use and the project, their meaning attributed to methadone, the factors contributing to project success and changes they experienced. Recordings, transcripts, notes and feedback were reviewed and triangulated. Key factors contributing to retention were identified and analysed in light of the existing literature. RESULTS The philosophy and architecture of the project, and social cohesion were identified as the main factors contributing to retention. The use of a harm reduction approach enabled participants to set and be supported to achieve their treatment goals, and was shown to be important for the development of trusting therapeutic relationships. The employment of a restorative justice paradigm provided a sense of acceptance of humanity and flaws as well as an imperative to act responsibly towards others, fostering a culture of respect. Social cohesion was fostered through the facilitation of group sessions, a peace committee and group sport (soccer). In concert, these activities provided opportunities for participants to demonstrate care and interest in one another's life, leading to interdependence and care, contributing to them remaining in the project. CONCLUSIONS We believe that the high retention was achieved through attraction. We argue that opioid agonist therapy programmes should take the principles of harm reduction and restorative justice into consideration when designing low-threshold opioid agonist therapy services. Additionally, ways to support cohesion amongst people receiving agonist therapy should be explored to support their effective scale-up, both in low-middle income countries and in high-income countries.
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Affiliation(s)
- Monique Marks
- Urban Futures Centre, Steve Biko Campus, Durban University of Technology, Durban, South Africa
| | - Andrew Scheibe
- Urban Futures Centre, Steve Biko Campus, Durban University of Technology, Durban, South Africa
- TB HIV Care, 7th Floor, 11 Adderley Street, Cape Town, South Africa
| | - Shaun Shelly
- Urban Futures Centre, Steve Biko Campus, Durban University of Technology, Durban, South Africa
- Department of Family Medicine, University of Pretoria, Pretoria, South Africa
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Weisshaar S, Brandt L, Litschauer B, Sheik-Rezaei S, Moser L, Nirnberger G, Kühberger E, Bauer U, Firbas C, Gouya G, Wolzt M, Fischer G. Dose-dependent naloxone-induced morphine withdrawal symptoms in opioid-dependent males-a double-blinded, randomized study. Br J Clin Pharmacol 2020; 86:1610-1619. [PMID: 32145041 PMCID: PMC7373709 DOI: 10.1111/bcp.14271] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 11/01/2019] [Accepted: 02/26/2020] [Indexed: 12/28/2022] Open
Abstract
Aims Oral opioid preparations combined with naloxone are intended to induce a transient acute withdrawal syndrome to avoid intravenous misuse. This trial aimed to establish an appropriate morphine–naloxone dose ratio for an abuse‐deterrent oral opioid formulation. Methods In a randomized, double‐blinded, 2 × 2 cross‐over trial, 43 patients with opioid use disorder were challenged with intravenous morphine HCl Ph.Eur. (75 mg; [morphine mono]) or morphine HCl Ph.Eur. and naloxone HCl Ph.Eur. at ratios of 100:1 (75 mg: 0.75 mg; [morphine–naloxone 100:1]) or 200:1 (75 mg: 0.375 mg; [morphine–naloxone 200:1]). Acute naloxone‐induced opioid withdrawal was evaluated using subjective (Short Opiate Withdrawal Scale–German [SOWS‐G]) and observer‐rated (Objective Opiate Withdrawal Scale [OOWS], Wang scale) questionnaires, and physiological parameters. For statistical analysis, the area under the curve between baseline and 20 minutes after drug administration of the outcome variables was calculated. Results Intravenous morphine–naloxone caused rapid withdrawal symptoms. Coadministration of naloxone dose‐dependently (morphine–naloxone 100:1 > morphine–naloxone 200:1) increased SOWS‐G, OOWS and Wang Scale area under the curve when compared to morphine mono, respectively (all P < .0001). A similar response was detectable for changes of pupil diameter. Blood pressure and respiratory rate changed heterogeneously, and heart rate was unaltered by morphine without or with naloxone. Conclusion Morphine–naloxone 100:1 effectively suppresses the pleasurable effects of intravenous morphine and results in an aversive withdrawal reaction. A lower naloxone concentration as used in morphine–naloxone 200:1 does not appear to be appropriate to prevent intravenous morphine misuse.
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Affiliation(s)
- Stefan Weisshaar
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Laura Brandt
- Department of Applied Psychology: Work, Education & Economy, Faculty of Psychology, University of Vienna, Vienna, Austria.,Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Brigitte Litschauer
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Safoura Sheik-Rezaei
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Laura Moser
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | | | | | | | - Christa Firbas
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Ghazaleh Gouya
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Michael Wolzt
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Gabriele Fischer
- Center for Public Health, Medical University of Vienna, Vienna, Austria
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4
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Mannaioni G, Lanzi C, Lotti M, Galli V, Totti A, Pacileo I, Sili M, Pracucci C, Dilaghi A, Bertieri L, Quaranta M, Orsini F, Occupati B, Michahelles A, Ciuti R, Bianchini E, Fabbro G, Biggeri A, Masini E, Moroni F. Methadone Dose Adjustments, Plasma R-Methadone Levels and Therapeutic Outcome of Heroin Users: A Randomized Clinical Trial. Eur Addict Res 2018; 24:9-18. [PMID: 29393208 DOI: 10.1159/000485029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 11/07/2017] [Indexed: 11/19/2022]
Abstract
AIMS We aimed to improve the retention in treatment and therapeutic outcome of methadone maintenance treatment (MMT) patients by adjusting the oral methadone dose in order to reach a "target" plasma R-methadone level (80-250 ng/mL). METHODS A multicenter randomized controlled trial was organized. RESULTS The intention-to-treat statistical analysis showed that repeated dose adjustments performed in order to obtain therapeutic plasma R-methadone levels did not improve retention in treatment of heroin-dependent patients. However, patients having plasma methadone levels in the "target range" at the beginning of the study had a better retention in treatment than controls. Furthermore, patients succeeding in keeping plasma R-methadone target levels (per protocol analysis) remained in treatment and improved their social scores better than controls. -Conclusion: Although the primary endpoint of this study was not demonstrated, a post hoc and a per protocol analysis suggested that patients in MMT with plasma R-methadone concentrations in the target range have a better therapeutic outcome than controls.
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Affiliation(s)
- Guido Mannaioni
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Cecilia Lanzi
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Michela Lotti
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Valentina Galli
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Arianna Totti
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Ilaria Pacileo
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Maria Sili
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Chiara Pracucci
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Arianna Dilaghi
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Lara Bertieri
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Mariarita Quaranta
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Francesco Orsini
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | | | | | | | | | | | | | - Emanuela Masini
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
| | - Flavio Moroni
- Department of NEUROFARBA, Pharmacology Section, University of Florence, Florence, Italy.,AOUC Hospital, Medical Toxicology Unit, Florence, Italy
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Landry M, Veilleux N, Arseneault JE, Abboud S, Barrieau A, Bélanger M. Impact of a methadone maintenance program on an Aboriginal community: a qualitative study. CMAJ Open 2016; 4:E431-E435. [PMID: 27730106 PMCID: PMC5047842 DOI: 10.9778/cmajo.20150076] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Methadone maintenance treatment programs implemented in Aboriginal communities have proven to be beneficial for the control of opioid addiction and its associated consequences, but the perceptions and opinions of different community members about these programs remain elusive. The goal of this study was to determine the perceptions of members of a First Nation community in New Brunswick, Canada, on the implementation of a methadone maintenance treatment program and its effects on the community. METHODS We conducted a qualitative study using semistructured focus group discussions with 3 distinct groups composed of health care professionals and influential community members, patients in the methadone maintenance treatment program and community members at large. Thematic analysis of discussion transcripts was performed. RESULTS A total of 22 partipants were included in the 3 focus groups. All groups of participants expressed that patients in the program are stigmatized and marginalized. Discussions also revealed widespread misconceptions about the program. Participants associated the program with improvements in community-level outcomes and in parenting abilities of patients, but also with difficulties preserving family unity. INTERPRETATION Despite being culturally adapted to the community, elements surrounding the methadone maintenance treatment program in this First Nation community appear to be misunderstood and stigmatized. It may be beneficial to provide community education on these programs to assure community buy-in for the successful implementation of harm reduction programs in Aboriginal communities.
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Affiliation(s)
- Michel Landry
- Department of Family Medicine (Landry, Bélanger, Veilleux, Arseneault, Abboud, Barrieau), Université de Sherbrooke, Sherbrooke, Que.; Centre de formation médicale du Nouveau-Brunswick (Bélanger, Veilleux, Arseneault, Landry, Abboud, Barrieau), Université de Moncton, Moncton, NB
| | - Nadia Veilleux
- Department of Family Medicine (Landry, Bélanger, Veilleux, Arseneault, Abboud, Barrieau), Université de Sherbrooke, Sherbrooke, Que.; Centre de formation médicale du Nouveau-Brunswick (Bélanger, Veilleux, Arseneault, Landry, Abboud, Barrieau), Université de Moncton, Moncton, NB
| | - Julie-Eve Arseneault
- Department of Family Medicine (Landry, Bélanger, Veilleux, Arseneault, Abboud, Barrieau), Université de Sherbrooke, Sherbrooke, Que.; Centre de formation médicale du Nouveau-Brunswick (Bélanger, Veilleux, Arseneault, Landry, Abboud, Barrieau), Université de Moncton, Moncton, NB
| | - Saneea Abboud
- Department of Family Medicine (Landry, Bélanger, Veilleux, Arseneault, Abboud, Barrieau), Université de Sherbrooke, Sherbrooke, Que.; Centre de formation médicale du Nouveau-Brunswick (Bélanger, Veilleux, Arseneault, Landry, Abboud, Barrieau), Université de Moncton, Moncton, NB
| | - André Barrieau
- Department of Family Medicine (Landry, Bélanger, Veilleux, Arseneault, Abboud, Barrieau), Université de Sherbrooke, Sherbrooke, Que.; Centre de formation médicale du Nouveau-Brunswick (Bélanger, Veilleux, Arseneault, Landry, Abboud, Barrieau), Université de Moncton, Moncton, NB
| | - Mathieu Bélanger
- Department of Family Medicine (Landry, Bélanger, Veilleux, Arseneault, Abboud, Barrieau), Université de Sherbrooke, Sherbrooke, Que.; Centre de formation médicale du Nouveau-Brunswick (Bélanger, Veilleux, Arseneault, Landry, Abboud, Barrieau), Université de Moncton, Moncton, NB
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Wang PC, Ho IK, Lee CWS. Buprenorphine-elicited alteration of adenylate cyclase activity in human embryonic kidney 293 cells coexpressing κ-, μ-opioid and nociceptin receptors. J Cell Mol Med 2015; 19:2587-96. [PMID: 26153065 PMCID: PMC4627564 DOI: 10.1111/jcmm.12644] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 05/28/2015] [Indexed: 02/03/2023] Open
Abstract
Buprenorphine, a maintenance drug for heroin addicts, exerts its pharmacological function via κ- (KOP), μ-opioid (MOP) and nociceptin/opioid receptor-like 1 (NOP) receptors. Previously, we investigated its effects in an in vitro model expressing human MOP and NOP receptors individually or simultaneously (MOP, NOP, and MOP+NOP) in human embryonic kidney 293 cells. Here, we expanded this cell model by expressing human KOP, MOP and NOP receptors individually or simultaneously (KOP, KOP+MOP, KOP+NOP and KOP+MOP+NOP). Radioligand binding with tritium-labelled diprenorphine confirmed the expression of KOP receptors. Immunoblotting and immunocytochemistry indicated that the expressed KOP, MOP and NOP receptors are N-linked glycoproteins and colocalized in cytoplasmic compartments. Acute application of the opioid receptor agonists— U-69593, DAMGO and nociceptin— inhibited adenylate cyclase (AC) activity in cells expressing KOP, MOP and NOP receptors respectively. Buprenorphine, when applied acutely, inhibited AC activity to ~90% in cells expressing KOP+MOP+NOP receptors. Chronic exposure to buprenorphine induced concentration-dependent AC superactivation in cells expressing KOP+NOP receptors, and the level of this superactivation was even higher in KOP+MOP+NOP-expressing cells. Our study demonstrated that MOP receptor could enhance AC regulation in the presence of coexpressed KOP and NOP receptors, and NOP receptor is essential for concentration-dependent AC superactivation elicited by chronic buprenorphine exposure.
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Affiliation(s)
- Pei-Chen Wang
- Neuropsychiatric Center, National Health Research Institutes, Miaoli County, Taiwan
| | - Ing-Kang Ho
- Neuropsychiatric Center, National Health Research Institutes, Miaoli County, Taiwan.,Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan.,Center for Drug Abuse and Addiction, China Medical University Hospital, Taichung, Taiwan
| | - Cynthia Wei-Sheng Lee
- Center for Drug Abuse and Addiction, China Medical University Hospital, Taichung, Taiwan.,China Medical University, Taichung, Taiwan
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7
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The antipsychotic aripiprazole selectively prevents the stimulant and rewarding effects of morphine in mice. Eur J Pharmacol 2014; 742:139-44. [DOI: 10.1016/j.ejphar.2014.09.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2014] [Revised: 09/01/2014] [Accepted: 09/02/2014] [Indexed: 01/23/2023]
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8
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Beck T, Haasen C, Verthein U, Walcher S, Schuler C, Backmund M, Ruckes C, Reimer J. Maintenance treatment for opioid dependence with slow-release oral morphine: a randomized cross-over, non-inferiority study versus methadone. Addiction 2014; 109:617-26. [PMID: 24304412 PMCID: PMC4226326 DOI: 10.1111/add.12440] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Revised: 10/11/2013] [Accepted: 11/03/2013] [Indexed: 12/01/2022]
Abstract
AIMS To compare the efficacy of slow-release oral morphine (SROM) and methadone as maintenance medication for opioid dependence in patients previously treated with methadone. DESIGN Prospective, multiple-dose, open label, randomized, non-inferiority, cross-over study over two 11-week periods. Methadone treatment was switched to SROM with flexible dosing and vice versa according to period and sequence of treatment. SETTING Fourteen out-patient addiction treatment centres in Switzerland and Germany. PARTICIPANTS Adults with opioid dependence in methadone maintenance programmes (dose ≥50 mg/day) for ≥26 weeks. MEASUREMENTS The efficacy end-point was the proportion of heroin-positive urine samples per patient and period of treatment. Each week, two urine samples were collected, randomly selected and analysed for 6-monoacetyl-morphine and 6-acetylcodeine. Non-inferiority was concluded if the two-sided 95% confidence interval (CI) in the difference of proportions of positive urine samples was below the predefined boundary of 10%. FINDINGS One hundred and fifty-seven patients fulfilled criteria to form the per protocol population. The proportion of heroin-positive urine samples under SROM treatment (0.20) was non-inferior to the proportion under methadone treatment (0.15) (least-squares mean difference 0.05; 95% CI = 0.02, 0.08; P > 0.01). The 95% CI fell within the 10% non-inferiority margin, confirming the non-inferiority of SROM to methadone. A dose-dependent effect was shown for SROM (i.e. decreasing proportions of heroin-positive urine samples with increasing SROM doses). Retention in treatment showed no significant differences between treatments (period 1/period 2: SROM: 88.7%/82.1%, methadone: 91.1%/88.0%; period 1: P = 0.50, period 2: P = 0.19). Overall, safety outcomes were similar between the two groups. CONCLUSIONS Slow-release oral morphine appears to be at least as effective as methadone in treating people with opioid use disorder.
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Affiliation(s)
- Thilo Beck
- Arud Centres for Addiction MedicineZurich, Switzerland,Correspondence to: Thilo Beck, Arud Zurich, Konradstrasse 32, 8005 Zurich, Switzerland. E-mail:
| | - Christian Haasen
- Centre for Interdisciplinary Addiction Research of Hamburg University, Department of Psychiatry, University Medical Centre EppendorfHamburg, Germany
| | - Uwe Verthein
- Centre for Interdisciplinary Addiction Research of Hamburg University, Department of Psychiatry, University Medical Centre EppendorfHamburg, Germany
| | | | | | - Markus Backmund
- Praxiszentrum im TalMunich, Germany,Ludwig-Maximilians-UniversitätMunich, Germany
| | - Christian Ruckes
- Interdisciplinary Centre for Clinical Trials (IZKS), University Medical Centre of the Johannes Gutenberg University MainzMainz, Germany
| | - Jens Reimer
- Centre for Interdisciplinary Addiction Research of Hamburg University, Department of Psychiatry, University Medical Centre EppendorfHamburg, Germany
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9
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Gerra G, Somaini L, Leonardi C, Cortese E, Maremmani I, Manfredini M, Donnini C. Association between gene variants and response to buprenorphine maintenance treatment. Psychiatry Res 2014; 215:202-7. [PMID: 24274990 DOI: 10.1016/j.psychres.2013.11.001] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 09/13/2013] [Accepted: 11/03/2013] [Indexed: 11/24/2022]
Abstract
A variety of studies were addressed to differentiate responders and non-responders to substitution treatment among heroin dependent patients, without conclusive findings. In particular, preliminary pharmacogenetic findings have been reported to predict treatment effectiveness in mental health and substance use disorders. Aim of the present study was to investigate the possible association of buprenorphine (BUP) treatment outcome with gene variants that may affect kappa-opioid receptors and dopamine system function. One hundred and seven heroin addicts (West European, Caucasians) who underwent buprenorphine maintenance treatment were genotyped and classified into two groups (A and B) on the basis of treatment outcome. Non-responders to buprenorphine (group B) have been identified taking into account early drop out, continuous use of heroin, severe behavioral or psychiatric problems, misbehavior and diversion during the 6 months treatment period. No difference was evidenced between responders and non-responders to BUP in the frequency of kappa opioid receptor (OPRK1) 36G>T SNP. The frequency of dopamine transporter (DAT) gene polymorphism (SLC6A3/DAT1), allele 10, was evidently much higher in "non-responder" than in "responder" individuals (64.9% vs. 55.93%) whereas the frequency of the category of other alleles (6, 7 and 11) was higher in responder than in non-responder individuals (11.02% vs. 2.13% respectively). On one hand, the hypothesis that possible gene-related changes in kappa-opioid receptor could consistently affect buprenorphine pharmacological action and clinical effectiveness was not confirmed in our study, at least in relation to the single nucleotide polymorphism 36G>T. On the other hand, the possibility that gene-related dopamine changes could have reduced BUP effectiveness and impaired maintenance treatment outcome was cautiously supported by our findings. DAT1 gene variants such as allele 10, previously reported in association with personality and behavioral problems, would have influenced the effects of BUP-induced dopamine release, modulated through mu and kappa opioid receptors, and probably the related reinforcing capacity of the drug.
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Affiliation(s)
- Gilberto Gerra
- Drug Prevention and Health Branch, Division for Operations, United Nation Office on Drugs and Crime, Vienna, Austria
| | - Lorenzo Somaini
- Addiction Treatment Center, Local Health Service, Cossato 13836, Biella, Italy.
| | - Claudio Leonardi
- Addiction Treatment Center, Local Health Service, Rome C 00179, Rome, Italy
| | - Elena Cortese
- Addiction Treatment Center, Local Health Service, Rome C 00179, Rome, Italy
| | - Icro Maremmani
- Department of Neurosciences, Santa Chiara University Hospital, University of Pisa, 56100 Pisa, Italy
| | - Matteo Manfredini
- Department of Life Sciences, University of Parma, Parma 43124, Italy
| | - Claudia Donnini
- Department of Life Sciences, University of Parma, Parma 43124, Italy
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10
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Viswanath B, Chand P, Benegal V, Murthy P. Agonist treatment in opioid use: advances and controversy. Asian J Psychiatr 2012; 5:125-31. [PMID: 22813654 DOI: 10.1016/j.ajp.2012.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Revised: 01/12/2012] [Accepted: 01/19/2012] [Indexed: 10/28/2022]
Abstract
Opioid dependence is a chronic relapsing condition which requires comprehensive care; pharmacological agents form the mainstay of its long term treatment. The two most popular approaches are the harm reduction method using agonists and the complete abstinence method using antagonists. Currently, particularly from the harm minimization perspective and the low feasibility of an abstinence based approach, there is an increasing trend toward agonist treatment. The use of buprenorphine has gained popularity in view of its safety profile and the availability of the buprenorphine-naloxone combination has made it popular as a take-home treatment. This review outlines the pharmacological advances and controversies in this area.
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Affiliation(s)
- Biju Viswanath
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore 560 029, India.
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11
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Marchand K, Oviedo-Joekes E, Guh D, Marsh DC, Brissette S, Schechter MT. Sex work involvement among women with long-term opioid injection drug dependence who enter opioid agonist treatment. Harm Reduct J 2012; 9:8. [PMID: 22276954 PMCID: PMC3281790 DOI: 10.1186/1477-7517-9-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Accepted: 01/25/2012] [Indexed: 11/10/2022] Open
Abstract
Background Substitution with opioid-agonists (e.g., methadone) has shown to be an effective treatment for chronic long-term opioid dependency. Survival sex work, very common among injection drug users, has been associated with poor Opioid Agonist Treatment (OAT) engagement, retention and response. Therefore, this study was undertaken to determine factors associated with engaging in sex work among long-term opioid dependent women receiving OAT. Methods Data from a randomized controlled trial, the North American Opiate Medication Initiative (NAOMI), conducted in Vancouver and Montreal (Canada) between 2005-2008, was analyzed. The NAOMI study compared the effectiveness of oral methadone to injectable diacetylmorphine or injectable hydromorphone, the last two on a double blind basis, over 12 months. A research team, independent of the clinic services, obtained outcome evaluations at baseline and follow-up (3, 6, 9, 12, 18 and 24 months). Results A total 53.6% of women reported engaging in sex work in at least one of the research visits. At treatment initiation, women who were younger and had fewer years of education were more likely to be engaged in sex work. The multivariate logistic generalized estimating equation regression analysis determined that psychological symptoms, and high illicit heroin and cocaine use correlated with women's involvement in sex work during the study period. Conclusions After entering OAT, women using injection drugs and engaging in sex work represent a particularly vulnerable group showing poorer psychological health and a higher use of heroin and cocaine compared to women not engaging in sex work. These factors must be taken into consideration in the planning and provision of OAT in order to improve treatment outcomes. Trial Registration NCT00175357.
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Affiliation(s)
- Kirsten Marchand
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St, Paul's Hospital 620B-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
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Colom Farran J, Casas M, Pérez de Los Cobos J, Del Río M, Roncero C, Castells X, Valero S, Eiroa-Orosa FJ, Batlle F, Trujols J. Feasibility of double-blind clinical trials with oral diacetylmorphine: a randomized controlled phase II study in an inpatient setting. Eur Addict Res 2012; 18:279-87. [PMID: 22854605 DOI: 10.1159/000336849] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 01/25/2012] [Indexed: 11/19/2022]
Abstract
The aim of this study was to evaluate the feasibility of conducting double-blind controlled randomized clinical trials using twice-a-day immediate-release oral diacetylmorphine (DAM) in heroin-dependent patients, by means of measuring the capacity of oral DAM to block opiate withdrawal and clinicians' ability to distinguish it from morphine and methadone. This was a randomized, phase II, double-blind, multicenter pilot study comparing immediate-release oral DAM, slow-release oral morphine and oral methadone administered twice a day during 10 days. Forty-five heroin-dependent patients were randomly assigned to these three treatment groups in an inpatient regime. Patients were stabilized with a mean of 350 mg (SD = 193) of immediate-release oral DAM, 108 mg (SD = 46.2) of slow-release oral morphine and 40 mg (SD = 17.9) of methadone. No statistically significant differences were found between any studied medication in clinical outcome. Neither patients nor clinicians were able to identify the administered medication. This study shows the feasibility of double-blind clinical trials using b.i.d. immediate-release oral DAM allowing further phase III clinical trials in the process of introducing oral DAM as a medication for heroin-dependent patients not responding to standard maintenance treatments.
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Affiliation(s)
- Joan Colom Farran
- Programme on Substance Abuse, Public Health Agency of Catalonia, Government of Catalonia, Barcelona, Spain.
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Lee CWS, Yan JY, Chiang YC, Hung TW, Wang HL, Chiou LC, Ho IK. Differential pharmacological actions of methadone and buprenorphine in human embryonic kidney 293 cells coexpressing human μ-opioid and opioid receptor-like 1 receptors. Neurochem Res 2011; 36:2008-21. [PMID: 21671107 PMCID: PMC3183316 DOI: 10.1007/s11064-011-0525-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2011] [Indexed: 11/26/2022]
Abstract
Methadone and buprenorphine are used in maintenance therapy for heroin addicts. In this study, we compared their effects on adenylate cyclase (AC) activity in human embryonic kidney (HEK) 293 cells stably overexpressing human μ-opioid receptor (MOR) and nociceptin/opioid receptor-like 1 receptor (ORL1) simultaneously. After acute exposure, methadone inhibited AC activity; however, buprenorphine induced compromised AC inhibition. When naloxone was introduced after 30 min incubation with methadone, the AC activity was enhanced. This was not observed in the case of buprenorphine. Enhancement of the AC activity was more significant when the incubation lasted for 4 h, and prolonged exposure to buprenorphine elevated the AC activity as well. The removal of methadone and buprenorphine by washing also obtained similar AC superactivation as that revealed by naloxone challenge. The study demonstrated that methadone and buprenorphine exert initially different yet eventually convergent adaptive changes of AC activity in cells coexpressing human MOR and ORL1 receptors.
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Affiliation(s)
- Cynthia Wei-Sheng Lee
- Division of Mental Health and Addiction Medicine, Institute of Population Health Sciences, National Health Research Institutes, 35 Keyan Road, Zhunan, Miaoli County, 35053 Taiwan
| | - Jia-Ying Yan
- Division of Mental Health and Addiction Medicine, Institute of Population Health Sciences, National Health Research Institutes, 35 Keyan Road, Zhunan, Miaoli County, 35053 Taiwan
| | - Yao-Chang Chiang
- Division of Mental Health and Addiction Medicine, Institute of Population Health Sciences, National Health Research Institutes, 35 Keyan Road, Zhunan, Miaoli County, 35053 Taiwan
| | - Tsai-Wei Hung
- Division of Mental Health and Addiction Medicine, Institute of Population Health Sciences, National Health Research Institutes, 35 Keyan Road, Zhunan, Miaoli County, 35053 Taiwan
| | - Hung-Li Wang
- Department of Physiology, Chang Gung University School of Medicine, Kwei-San, Taoyuan, 33302 Taiwan
| | - Lih-Chu Chiou
- Department of Pharmacology, College of Medicine, National Taiwan University, Taipei, 10051 Taiwan
| | - Ing-Kang Ho
- Division of Mental Health and Addiction Medicine, Institute of Population Health Sciences, National Health Research Institutes, 35 Keyan Road, Zhunan, Miaoli County, 35053 Taiwan
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BOND ALYSONJ, REED KYLIED, BEAVAN PETE, STRANG JOHN. After the randomised injectable opiate treatment trial: Post-trial investigation of slow-release oral morphine as an alternative opiate maintenance medication. Drug Alcohol Rev 2011; 31:492-8. [DOI: 10.1111/j.1465-3362.2011.00353.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Reimer J, Verthein U, Karow A, Schäfer I, Naber D, Haasen C. Physical and mental health in severe opioid-dependent patients within a randomized controlled maintenance treatment trial. Addiction 2011; 106:1647-55. [PMID: 21489005 DOI: 10.1111/j.1360-0443.2011.03463.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS To evaluate physical and mental health and compare treatment outcomes in opiate-dependent patients substituted either with heroin or methadone. DESIGN Twelve-month open-label randomized controlled trial. SETTING Out-patient substitution clinics in seven German cities. PARTICIPANTS A total of 1015 opiate-dependent individuals. MEASUREMENTS Opiate Treatment Index-Health Scale Score (OTI), Body Mass Index (BMI), serology for infectious diseases such as hepatitis B, C and human immunodeficiency virus as well as tuberculosis, Karnofsky Performance Scale (KPS), electrocardiogram (ECG), echocardiogram, Symptom Checklist 90-R (SCL-90-R), Global Assessment of Functioning (GAF), Modular System for Quality of Life and study medication-related serious adverse events (SAE). FINDINGS Improvements were found in both heroin and methadone substituted patients regarding OTI, BMI, KPS, SCL-90-R, and GAF, but they were more pronounced for the heroin group (analysis of variance, all P = 0.000). The frequency of pathological echocardiograms decreased in the heroin group and increased in the methadone group (χ(2) test, <0.05). Markers for infectious diseases and frequencies of pathological ECGs did not differ between baseline and 12 months, or between treatment groups. Study medication-related serious adverse events, all of which were treated successfully, occurred 2.5 times more often in the heroin group. The majority of heroin-related SAEs (41 of 58) occurred within a few minutes of the injections. CONCLUSIONS The integration of severe injection drug users either in methadone or heroin-assisted maintenance treatment has positive effects on most physical and mental change-sensitive variables, with heroin showing superior results. Due to medication-related adverse events, patients should be observed for 15 minutes after a heroin injection.
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Affiliation(s)
- Jens Reimer
- Centre for Interdisciplinary Addiction Research, University of Hamburg, Hamburg, Germany.
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Eiroá-Orosa FJ, Verthein U, Kuhn S, Lindemann C, Karow A, Haasen C, Reimer J. Implication of gender differences in heroin-assisted treatment: results from the German randomized controlled trial. Am J Addict 2010; 19:312-8. [PMID: 20653637 DOI: 10.1111/j.1521-0391.2010.00049.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Despite a lower prevalence of opioid dependence among females, drug-related problems and risk factors such as prostitution have a negative effect for women in treatment. This study was conducted with the purpose of analyzing gender differences in the German trial on heroin-assisted treatment (HAT), which compared HAT with methadone maintenance treatment (MMT). Significant baseline gender differences were found, with females showing a greater extent of mental distress. Differences in retention and outcome were significant for male patients, but no differences between treatment options were found for female patients. Ongoing prostitution was found to influence drug use outcomes. Other outcome criteria may need to be stressed when assessing the effect of HAT for women.
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Blanken P, Hendriks VM, van Ree JM, van den Brink W. Outcome of long-term heroin-assisted treatment offered to chronic, treatment-resistant heroin addicts in the Netherlands. Addiction 2010; 105:300-8. [PMID: 19922517 DOI: 10.1111/j.1360-0443.2009.02754.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIMS To describe 4-year treatment retention and treatment response among chronic, treatment-resistant heroin-dependent patients offered long-term heroin-assisted treatment (HAT) in the Netherlands. DESIGN Observational cohort study. SETTING AND INTERVENTION Out-patient treatment in specialized heroin treatment centres in six cities in the Netherlands, with methadone plus injectable or inhalable heroin offered 7 days per week, three times per day. Prescription of methadone plus heroin was supplemented with individually tailored psychosocial and medical support. PARTICIPANTS Heroin-dependent patients who had responded positively to HAT in two randomized controlled trials and were eligible for long-term heroin-assisted treatment (n = 149). MEASUREMENTS Primary outcome measures were treatment retention after 4 years and treatment response on a dichotomous, multi-domain response index, comprising physical, mental and social health and illicit substance use. FINDINGS Four-year retention was 55.7% [95% confidence interval (CI): 47.6-63.8%]. TREATMENT Response was significantly better for patients continuing 4 years of HAT compared to patients who discontinued treatment: 90.4% versus 21.2% [difference 69.2%; odds ratio (OR) = 48.4, 95% CI: 17.6-159.1]. Continued HAT treatment was also associated with an increasing proportion of patients without health problems and who had stopped illicit drug and excessive alcohol use: from 12% after the first year to 25% after 4 years of HAT. CONCLUSIONS Long-term HAT is an effective treatment for chronic heroin addicts who have failed to benefit from methadone maintenance treatment. Four years of HAT is associated with stable physical, mental and social health and with absence of illicit heroin use and substantial reductions in cocaine use. HAT should be continued as long as there is no compelling reason to stop treatment.
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Affiliation(s)
- Peter Blanken
- Central Committee on the Treatment of Heroin Addicts, University Medical Centre Utrecht, Stratenum 5th Floor, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands.
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Müller MC, Pichler M, Martin G, Plörer D, Winter C, Pogarell O, Bogner JR. [Burden of disease and level of patient's medical care in substitution treatment for opiates]. ACTA ACUST UNITED AC 2009; 104:913-7. [PMID: 20039157 DOI: 10.1007/s00063-009-1196-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2009] [Accepted: 11/18/2009] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND PURPOSE Within the framework of an interdisciplinary cooperation, the authors set up an on-site medical service provider in a specialized methadone substitution center in Germany. Here, they report on the prevalence of infectious and noninfectious diseases, and the vaccination status of substituted heroin-dependent patients. PATIENTS AND METHODS All patients who visited the medical care service provider between February 2008 and December 2008 were included in this study. RESULTS Ten patients (7%) were seropositive for the hepatitis A virus. Two patients (1.3%) suffered from chronic hepatitis B; 40 patients (27%) were cured after a hepatitis B infection. Additionally, 99 patients (68%) were infected with hepatitis C virus (HCV), and 41 patients (28%) had active hepatitis C. Furthermore, 48 hepatitis C patients (33%) were cured. Of those, 25 patients (17%) cleared the virus spontaneously and 23 (16%) after ribavirin/interferon combination therapy. Ten (7%) of 146 patients were infected with the human immunodeficiency virus (HIV). Of those, four patients had active hepatitis C, and five patients were cured after a hepatitis C infection. 18 patients (12%) were vaccinated against hepatitis A and 28 (19%) against hepatitis B. Two of the 41 patients with chronic hepatitis C were vaccinated against hepatitis A. The most frequent noninfectious diagnoses were arterial hypertension (n = 28), bronchial asthma (n = 8), and diffuse liver parenchymal damage (n = 12). CONCLUSION These results emphasize that i.v. drug users on substitution therapy are an underserved collective with a high prevalence of disease. The challenge consists in facilitating this population access to internistic and infectious disease service. The offer of an on-site medical service was well accepted. This is essential for an ongoing reduction of HIV and HCV prevalence in the drug users.
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Affiliation(s)
- Matthias C Müller
- Infektionsabteilung, Medizinische Poliklinik, Campus Innenstadt, Klinikum der Universität München, München.
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Heikman PK, Ojanperä IA. Inadequate Dose of Opioid-agonist Medication is Related to Misuse of Benzodiazepines. ADDICTIVE DISORDERS & THEIR TREATMENT 2009. [DOI: 10.1097/adt.0b013e31817ea8b8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Coffin P. Balancing the costs and benefits of opioid analgesics in the United States. Public Health 2009; 123:147-8; discussion 149-50. [DOI: 10.1016/j.puhe.2008.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2008] [Accepted: 12/04/2008] [Indexed: 10/21/2022]
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Yang Z, Shao YC, Li SJ, Qi JL, Zhang MJ, Hao W, Jin GZ. Medication of l-tetrahydropalmatine significantly ameliorates opiate craving and increases the abstinence rate in heroin users: a pilot study. Acta Pharmacol Sin 2008; 29:781-8. [PMID: 18565275 DOI: 10.1111/j.1745-7254.2008.00817.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
AIM Drug addiction is a chronic brain disease with constant relapse requiring long-term treatment. New pharmacological strategies focus on the development of an effective antirelapse drug. This study examines the effects of levotetrahydropalmatine (l-THP) on reducing heroin craving and increasing the abstinence rate among heroin-dependent patients. METHODS In total, 120 heroin-dependent patients participated in the randomized, double-blinded, and placebocontrolled study using l-THP treatment. The participants remained in a ward during a 4-week period of l-THP treatment, followed by 4 weeks of observation after treatment. The patients were followed for 3 months after discharge. Outcome measures are the measured severity of the protracted abstinence withdrawal syndrome (PAWS) and the abstinence rate. RESULTS Four weeks of l-THP treatment significantly ameliorated the severity of PAWS, specifically, somatic syndrome, mood states, insomnia, and drug craving, in comparison to the placebo group. Based on the 3 month follow-up observation, participants who survived the initial 2 weeks of l-THP medication and remained in the trial program had a significantly higher abstinence rate of 47.8% (95% confidence interval [CI]: 33%- 67%) than the 15.2% in the placebo group (95% CI: 7%-25%), according to a log- rank test (P<0.0005). CONCLUSION l-THP significantly ameliorated PAWS, especially reducing drug craving. Furthermore, it increased the abstinence rate among heroin users. These results support the potential use of l-THP for the treatment of heroin addiction.
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Affiliation(s)
- Zheng Yang
- Beijing Institute of Basic Medical Science, Beijing 100005, China
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Bauer SM, Loipl R, Jagsch R, Gruber D, Risser D, Thau K, Fischer G. Mortality in opioid-maintained patients after release from an addiction clinic. Eur Addict Res 2008; 14:82-91. [PMID: 18334818 DOI: 10.1159/000113722] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
AIM To investigate the mortality rate in a cohort of 269 opioid-dependent patients and the outcome of survivors meeting DSM-IV criteria for opioid dependence. DESIGN Retrospective cohort study. PARTICIPANTS Patients enrolled in synthetic opioid maintenance therapy during a time frame from 1998 to 1999 originally at the Addiction Clinic and then discharged to general practitioners. METHODS Structured interviews (Europ-ASI), urinalysis at time of interview as well as autopsy findings from deceased patients. RESULTS After six mailings, information from 147 (54.6%) patients was gained. 85 patients (31.6%) were interviewed. From these 76.5% (n = 65) were still enrolled in maintenance therapy, 18.8% (n = 16) were drug-free and 4.7% (n = 4) relapsed. From 29 fatalities, 37.9% died of intoxication with illicit substances, 34.5% related to AIDS and 27.6% of somatic complications. The Standardized Mortality Ratio (SMR) was 29.13 (95% CI = 19.27-44.04). A higher lifetime frequency of hospitalization, less working days and a lack of social relationships were factors associated with high mortality. CONCLUSIONS The study confirms the high mortality rate in this patient group and supports the importance of maintenance therapy. Although great efforts were undertaken in locating patients, about 45% of the target group could not be located.
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Affiliation(s)
- Susanne M Bauer
- Department of Psychiatry and Psychotherapy, Division of Biological Psychiatry, Medical University of Vienna, Vienna, Austria
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Aeschbach Jachmann C, Jagsch R, Winklbaur B, Matzenauer C, Fischer G. Office-based treatment in opioid dependence: a critical survey of prescription practices for opioid maintenance medications and concomitant benzodiazepines in Vienna, Austria. Eur Addict Res 2008; 14:206-12. [PMID: 18583918 DOI: 10.1159/000141645] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The success of maintenance treatment for opioid dependence in office-based settings is influenced by the extent of treatment coverage, the availability of effective medications and the capacity of general practitioners to prescribe opioids in adequate doses with a minimum of concomitant benzodiazepine prescriptions. METHODS This study compares prescriptions for opioid maintenance and concomitant benzodiazepine from Viennese physicians in 2002 and 2005 using health insurance prescription records (n = 30,309). RESULTS Between 2002 and 2005, the number of patients prescribed opioids more than doubled (ratio 1:2.3), slow-release oral morphine replaced methadone as the most frequently prescribed medication (57.1 vs. 23.4%; buprenorphine 19.5%), and the ratio of benzodiazepine to opioid prescriptions significantly declined (0.76:1 vs. 0.42:1). Many patients were prescribed concomitant benzodiazepines (27%), in some cases from a secondary physician. CONCLUSION Increased utilization of opioid medications in office-based settings will facilitate better treatment coverage. However, safeguards are necessary to ensure that general practitioners have sufficient training and support to safely and appropriately provide treatment, including the reduction in concomitant benzodiazepine use.
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Michels II, Stöver H, Gerlach R. Substitution treatment for opioid addicts in Germany. Harm Reduct J 2007; 4:5. [PMID: 17270059 PMCID: PMC1797169 DOI: 10.1186/1477-7517-4-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2006] [Accepted: 02/02/2007] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND After a long and controversial debate methadone maintenance treatment (MMT) was first introduced in Germany in 1987. The number of patients in MMT--first low because of strict admission criteria--increased considerably since the 1990s up to some 65,000 at the end of 2006. In Germany each general practitioner (GP), who has completed an additional training in addiction medicine, is allowed to prescribe substitution drugs to opioid dependent patients. Currently 2,700 GPs prescribe substitution drugs. Psychosocial care should be made available to all MMT patients. RESULTS The results of research studies and practical experiences clearly indicate that patients benefit substantially from MMT with improvements in physical and psychological health. MMT proves successful in attaining high retention rates (65% to 85% in the first years, up to 50% after more than seven years) and plays a major role in accessing and maintaining ongoing medical treatment for HIV and hepatitis. MMT is also seen as a vital factor in the process of social re-integration and it contributes to the reduction of drug related harms such as mortality and morbidity and to the prevention of infectious diseases. Some 10% of MMT patients become drug-free in the long run. Methadone is the most commonly prescribed substitution medication in Germany, although buprenorphine is attaining rising importance. Access to MMT in rural areas is very patchy and still constitutes a problem. There are only few employment opportunities for patients participating in MMT, although regular employment is considered unanimously as a positive factor of treatment success. Substitution treatment in German prisons is heterogeneous in access and treatment modalities. Access is very patchy and the number of inmates in treatment is limited. Nevertheless, substitution treatment plays a substantial part in the health care system provided to drug users in Germany. CONCLUSION In Germany, a history of substitution treatment spanning 20 years has meanwhile accumulated a wealth of experience, e.g. in the development of research on health care services, guidelines and the implementation of quality assurance measures. Implementing substitution treatment with concomitant effects and treatment elements such as drug history-taking, dosage setting, co-use of other psychoactive substances (alcohol, benzodiazepines, cocaine), management of 'difficult patient populations', and integration into the social environment has been arranged successfully. Also psychosocial counseling programmes adjuvant to substitution treatment have been established and, in the framework of a pilot project on heroin-based treatment, standardised manuals were developed. Research on allocating opioid users to the 'right' form of therapy at the 'right' point in time is still a challenge, though the pilot project 'heroin-based treatment' brought experience with patients who do not benefit from methadone treatment. There is also expertise in the treatment of specific co-morbidity such as HIV/AIDS, hepatitis and psychiatric disorders. The promotion and involvement of self-help groups plays an important part in the process of successful substitution treatment.
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Affiliation(s)
- Ingo Ilja Michels
- Head of the Office of the Federal Drug Commissioner, Federal Ministry of Health, Berlin, Germany (from 2006-2008: Shanghai/PR China)
| | - Heino Stöver
- Bremen Institute of Drug Research, University of Bremen, Germany
| | - Ralf Gerlach
- Deputy Director, Institute for the Advancement of Qualitative Drug Research (INDRO), Münster, Germany
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