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Mackay L, Kerr T, Fairbairn N, Grant C, Milloy MJ, Hayashi K. The relationship between opioid agonist therapy satisfaction and fentanyl exposure in a Canadian setting. Addict Sci Clin Pract 2021; 16:26. [PMID: 33910630 PMCID: PMC8082888 DOI: 10.1186/s13722-021-00234-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 04/15/2021] [Indexed: 11/24/2022] Open
Abstract
Background While patient-reported treatment dissatisfaction is considered an important factor in determining the success of substance use disorder treatment, the levels of dissatisfaction with opioid agonist therapies (OAT) and its relationship with the risk of fentanyl exposure have not been characterized in the context of the ongoing opioid overdose crisis in the US and Canada. Our primary hypothesis was that OAT dissatisfaction was associated with an increased odds of fentanyl exposure. Methods Our objective was to examine self-reported treatment satisfaction among OAT patients in Vancouver, Canada and the association with fentanyl exposure. Longitudinal data were derived from 804 participants on OAT enrolled in two community-recruited harmonized prospective cohort studies of people who use drugs in Vancouver between 2016 and 2018 via semi-annual interviews and urine drug screens (UDS). We employed multivariable generalized estimating equations to examine the relationship between OAT dissatisfaction and fentanyl exposure. Results Out of 804 participants (57.0% male), 222 (27.6%) reported being dissatisfied with OAT at baseline and 1070 out of 1930 observations (55.4%) had fentanyl exposure. The distribution of OAT reported in the sample was methadone (n = 692, 77.7%), buprenorphine-naloxone (n = 82, 9.2%), injectable OAT (i.e., diacetylmorphine or hydromorphone; (n = 65, 7.3%), slow-release oral morphine (n = 44, 4.9%) and other/study medication (n = 8, 1.0%). In the multivariable analysis, OAT dissatisfaction was positively associated with fentanyl exposure (AOR = 1.34; 95% CI: 1.08–1.66). Conclusions A substantial proportion of OAT patients in our sample reported dissatisfaction with their OAT, and more than half were exposed to fentanyl. We also found that those who were dissatisfied with their OAT were more likely to be exposed to fentanyl. These findings demonstrate the importance of optimizing OAT satisfaction in the context of the ongoing opioid overdose crisis.
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Affiliation(s)
- Lindsay Mackay
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Nadia Fairbairn
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Cameron Grant
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
| | - M-J Milloy
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada. .,Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada.
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Mella-Raipán J, Romero-Parra J, Recabarren-Gajardo G. DARK Classics in Chemical Neuroscience: Heroin and Desomorphine. ACS Chem Neurosci 2020; 11:3905-3927. [PMID: 32568519 DOI: 10.1021/acschemneuro.0c00262] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Opioids are arguably one of the most important pharmacologic classes, mainly due to their rich history, their useful and potent analgesic effects, and also, just as importantly, their "Dark Side", constituted by their reinforcing properties that have led countless of users to a spiral of addiction, biological dependence, tolerance, withdrawal syndromes, and death. Among the most significant abused and addictive known opioids are heroin and desomorphine, both synthetic derivatives of morphine that belong to the 4,5-epoxymorphinan structural chemical group of the opioid family drugs. These agents share not only structural, pharmacological, and epidemiological features but also a common geographical distribution. A drop in Afghan heroin production and its "exports" to Russia gave rise to widespread consumption of desomorphine in ex-Soviet republics during the first decade of the 21st century, representing an economical and accessible alternative for misusers to this sort of derivative. Herein we review the state of the art of history, chemistry and synthesis, pharmacology, and impact on society of these "cursed cousins".
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Affiliation(s)
- Jaime Mella-Raipán
- Instituto de Quı́mica y Bioquı́mica, Facultad de Ciencias, Universidad de Valparaı́so, Av. Gran Bretaña 1111, Valparaı́so 2360102, Chile
- Facultad de Farmacia, Centro de Investigación Farmacopea Chilena, Universidad de Valparaı́so,, Av. Gran Bretaña 1093, Valparaı́so 2360102, Chile
| | - Javier Romero-Parra
- Departamento de Quı́mica Orgánica y Fisicoquı́mica, Facultad de Ciencias Quı́micas y Farmacéuticas, Universidad de Chile, Sergio Livingstone 1007, Casilla
233, 8380492 Santiago, Chile
| | - Gonzalo Recabarren-Gajardo
- Bioactive Heterocycles Synthesis Laboratory, BHSL, Departamento de Farmacia, Facultad de Quı́mica y de Farmacia, Pontificia Universidad Católica de Chile, Casilla 306, Avda. Vicuña Mackenna 4860, Macul, 7820436 Santiago, Chile
- Centro Interdisciplinario de Neurociencias, Pontificia Universidad Católica de Chile,, Marcoleta 391, 8330024 Santiago, Chile
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Pérez de Los Cobos J, Trujols J, Alcaraz S, Siñol N, Lozano Ó, González-Saiz F. Development and validation of the scale to assess satisfaction with medications for addiction treatment - Buprenorphine-naloxone for heroin addiction (SASMAT-BUNHER). THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 58:126-134. [PMID: 29957563 DOI: 10.1016/j.drugpo.2018.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 03/23/2018] [Accepted: 06/11/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Until now, no specific tool has been available to measure heroin-dependent patient satisfaction with buprenorphine-naloxone as a medication. The purpose of the present study was to develop the Scale to Assess Satisfaction with Medications for Addiction Treatment-Buprenorphine-Naloxone for Heroin addiction (SASMAT-BUNHER) and to examine its validity and reliability. METHODS The SASMAT-BUNHER was developed from a pool of 44 self-administered items grouped into nine theoretical domains, as follows: Overall Satisfaction, Pharmacotherapy, Initiation, Anti-Addictive Effect on Heroin, Mental State, Physical State, Personal Functioning, Acceptability, and Anti-Addictive Effect on Secondary Substances. The Treatment Satisfaction Questionnaire for Medication 1.4 version (TSQM 1.4) was used for convergent validation. Participants were 316 heroin-dependent patients in maintenance treatment with buprenorphine-naloxone sublingual tablets at 16 different treatment centres. RESULTS Principal component analysis of the SASMAT-BUNHER revealed a 5-factor structure that accounted for 65.1% of total variance. Based on similarities between empirically-obtained factors and theoretical domains, Factors 1 through 5 were named 'Mental and Physical State' (10 items), 'Anti-Addictive Effect on Other Substances' (5 items), 'Anti-Addictive Effect on Heroin' (4 items), 'Personal Functioning' (3 items), and 'Acceptability' (4 items). All factors showed acceptable internal consistency (Cronbach's alpha coefficients: 0.744-0.925) and test-retest reliability (intraclass correlation coefficients: 0.704-0.895). Correlation between SASMAT-BUNHER and TSQM 1.4 total scores was moderate (Pearson r = 0.552). Moreover, SASMAT-BUNHER total scores of patients reporting absence of buprenorphine-naloxone side effects were higher than those of their counterparts. CONCLUSION These results support the validity and reliability of the SASMAT-BUNHER.
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Affiliation(s)
- José Pérez de Los Cobos
- Addictive Behaviours Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain; Departament de Psiquiatria i Medicina Legal, Universitat Autonoma de Barcelona, Bellaterra, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain.
| | - Joan Trujols
- Addictive Behaviours Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain.
| | - Saul Alcaraz
- Addictive Behaviours Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.
| | - Núria Siñol
- Addictive Behaviours Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.
| | - Óscar Lozano
- Departamento de Psicología Clínica, Experimental y Social, Universidad de Huelva, Huelva, Spain; Red de Trastornos Adictivos, Grupo de Investigación en Neurociencias Traslacional en Adicciones (GRINTA), Universidad de Granada, Granada, Spain.
| | - Francisco González-Saiz
- Red de Trastornos Adictivos, Grupo de Investigación en Neurociencias Traslacional en Adicciones (GRINTA), Universidad de Granada, Granada, Spain; Unidad de Salud Mental Comunitaria Villamartín, UGC Salud Mental, Área de Gestión Sanitaria Norte de Cádiz, Servicio Andaluz de Salud, Jerez dela Frontera, Spain.
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Alcaraz S, González-Saiz F, Trujols J, Vergara-Moragues E, Siñol N, Pérez de Los Cobos J. A cluster-analytic profiling of heroin-dependent patients based on level, clinical adequacy, and patient-desired adjustment of buprenorphine dosage during buprenorphine-naloxone maintenance treatment in sixteen Spanish centers. Drug Alcohol Depend 2018; 187:278-284. [PMID: 29702336 DOI: 10.1016/j.drugalcdep.2018.02.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 02/14/2018] [Accepted: 02/24/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Buprenorphine dosage is a crucial factor influencing outcomes of buprenorphine treatment for heroin use disorders. Therefore, the aim of the present study is to identify naturally occurring profiles of heroin-dependent patients regarding individualized management of buprenorphine dosage in clinical practice of buprenorphine-naloxone maintenance treatment. METHODS 316 patients receiving buprenorphine-naloxone maintenance treatment were surveyed at 16 Spanish centers during the stabilization phase of this treatment. Patients were grouped using cluster analysis based on three key indicators of buprenorphine dosage management: dose, adequacy according to physician, and adjustment according to patient. The clusters obtained were compared regarding different facets of patient clinical condition. RESULTS Four clusters were identified and labeled as follows (buprenorphine average dose and percentage of participants in each cluster are given in brackets): "Clinically Adequate and Adjusted to Patient Desired Low Dosage" (2.60 mg/d, 37.05%); "Clinically Adequate and Adjusted to Patient Desired High Dosage" (10.71 mg/d, 29.18%); "Clinically Adequate and Patient Desired Reduction of Low Dosage" (3.38 mg/d, 20.0%); and "Clinically Inadequate and Adjusted to Patient Desired Moderate Dosage" (7.55 mg/d, 13.77%). Compared to patients from the other three clusters, participants in the latter cluster reported more frequent use of heroin and cocaine during last week, lower satisfaction with buprenorphine-naloxone as a medication, higher prevalence of buprenorphine-naloxone adverse effects and poorer psychological adjustment. CONCLUSIONS Our results show notable differences between clusters of heroin-dependent patients regarding buprenorphine dosage management. We also identified a group of patients receiving clinically inadequate buprenorphine dosage, which was related to poorer clinical condition.
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Affiliation(s)
- Saul Alcaraz
- Addictive Behaviours Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.
| | - Francisco González-Saiz
- Instituto de Investigación e Innovación Biomédica de Cádiz (INiBICA), Cádiz, Spain; Unidad de Salud Mental Comunitaria Villamartín, UGC Salud Mental, Área de Gestión Sanitaria Norte de Cádiz, Servicio Andaluz de Salud, Jerez de la Frontera, Spain
| | - Joan Trujols
- Addictive Behaviours Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain; Grup de Tècniques Estadístiques Avançades Aplicades a la Psicologia (GTEAAP), Universitat de Barcelona (UB), Barcelona, Spain
| | | | - Núria Siñol
- Addictive Behaviours Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - José Pérez de Los Cobos
- Addictive Behaviours Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain; Departament de Psiquiatria i Medicina Legal, Universitat Autonoma de Barcelona, Bellaterra, Spain
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Alcaraz S, Viladrich C, Trujols J, Siñol N, Pérez de Los Cobos J. Heroin-dependent patient satisfaction with methadone as a medication influences satisfaction with basic interventions delivered by staff to implement methadone maintenance treatment. Patient Prefer Adherence 2018; 12:1203-1211. [PMID: 30022813 PMCID: PMC6044354 DOI: 10.2147/ppa.s164181] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The aim of the present study was to test a structural equation model of patient satisfaction with different key facets of methadone maintenance treatment (MMT). In this model, the three dimensions of patient satisfaction with methadone as a medication (ie, personal functioning and well-being, anti-addictive effect on heroin, and anti-addictive effect on non-opioid substances) were expected to predict satisfaction with the basic interventions delivered by the staff of treatment centers to implement MMT. PATIENTS AND METHODS A sample of 210 heroin-dependent patients, resistant to MMT treatment (mean age =41.66 years, SD =6.50; 75.7% male), participated voluntarily in this study. Preliminary analysis based on exploratory structural equation modeling supported the expected three-factor measurement model of the scale to assess satisfaction with medications for addiction treatment - methadone for heroin addiction. Moreover, the 15 items measuring staff's basic interventions were shown to be compatible with the expected single-factor measurement model. Then, both measurement models were included in a structural model. RESULTS Results of this model show that patient satisfaction with the compatibility of methadone with personal functioning and well-being, as well as with the anti-addictive effects of methadone on non-opioid substances, predicts satisfaction with basic interventions conducted at methadone treatment centers (β=0.191 and β=0.152, respectively). CONCLUSION Our results provide further understanding regarding patient satisfaction with MMT, which could help professionals to better understand patient perspective and experience during MMT.
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Affiliation(s)
- Saul Alcaraz
- Addictive Behaviors Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain,
| | - Carme Viladrich
- Department of Psychobiology and Methodology of Health Sciences, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Joan Trujols
- Addictive Behaviors Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain,
- Biomedical Research Networking Center on Mental Health (CIBERSAM), Madrid, Spain
| | - Núria Siñol
- Addictive Behaviors Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain,
| | - José Pérez de Los Cobos
- Addictive Behaviors Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain,
- Biomedical Research Networking Center on Mental Health (CIBERSAM), Madrid, Spain
- Department of Psychiatry and Legal Medicine, School of Medicine, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
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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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Pérez de Los Cobos J, Alcaraz S, Siñol N, Arranz MJ, Trujols J, Batlle F, Calafell F, Durán-Sindreu S, Salazar J. Satisfaction With Methadone and Opioid Receptor Genes Polymorphisms in Treatment-Refractory Heroin-Dependent Patients. J Clin Psychopharmacol 2017; 37:378-380. [PMID: 28338547 DOI: 10.1097/jcp.0000000000000698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- José Pérez de Los Cobos
- Addictive Behaviors Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Barcelona and Departament de Psiquiatria i Medicina Legal, Universitat Autonoma de Barcelona, Bellaterra and CIBER de Salud Mental, Madrid, Spain. ; Addictive Behaviors Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Barcelona, Spain; Fundació Docència i Recerca Mútua Terrassa, Terrassa, Spain; Addictive Behaviors Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Barcelona and CIBER de Salud Mental, Madrid, Spain; Addictive Behaviors Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Barcelona, Spain; Institut de Biologia Evolutiva (CSIC-UPF), Barcelona, Spain; Addictive Behaviors Unit, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Barcelona and CIBER de Salud Mental, Madrid, Spain; Genetics Department, Hospital de la Santa Creu i Sant Pau and Centre for Biomedical Network Research on Rare Diseases (CIBERER)Barcelona, Spain
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