The role of Cochrane reviews in informing international guidelines: a case study of using the Grading of Recommendations, Assessment, Development and Evaluation system to develop World Health Organization guidelines for the psychosocially assisted pharmacological treatment of opioid dependence

Large variations in all-cause and overdose mortality among >13,000 patients in and out of opioid maintenance treatment in different settings: a comparative registry linkage study

Background

Opioid maintenance treatment (OMT) has the potential to reduce mortality rates substantially. We aimed to compare all-cause and overdose mortality among OMT patients while in or out of OMT in two different countries with different approaches to OMT.

Methods

Two nation-wide, registry-based cohorts were linked by using similar analytical strategies. These included 3,637 male and 1,580 female patients enrolled in OMT in Czechia (years 2000-2019), and 6,387 male and 2,078 female patients enrolled in OMT in Denmark (years 2007-2018). The direct standardization method using the European (EU-27 plus EFTA 2011-2030) Standard was employed to calculate age-standardized rate to weight for age. All-cause and overdose crude mortality rates (CMR) as number of deaths per 1,000 person years (PY) in and out of OMT were calculated for all patients. CMRs were stratified by sex and OMT medication modality (methadone, buprenorphine, and buprenorphine with naloxone).

Results

Age-standardized rate for OMT patients in Czechia and Denmark was 9.7/1,000 PY and 29.8/1,000 PY, respectively. In Czechia, the all-cause CMR was 4.3/1,000 PY in treatment and 10.8/1,000 PY out of treatment. The overdose CMR was 0.5/1,000 PY in treatment and 1.2/1,000 PY out of treatment. In Denmark, the all-cause CMR was 26.6/1,000 PY in treatment and 28.2/1,000 PY out of treatment and the overdose CMR was 7.3/1,000 PY in treatment and 7.0/1,000 PY out of treatment.

Conclusion

Country-specific differences in mortality while in and out of OMT in Czechia and Denmark may be partly explained by different patient characteristics and treatment systems in the two countries. The findings contribute to the public health debate about OMT management and may be of interest to practitioners, policy and decision makers when balancing the safety and accessibility of OMT.

The influence of evidence-based program registry websites for dissemination of evidence-based interventions in behavioral healthcare

PURPOSE

Evidence-based program registries (EBPRs) are web-based databases of evaluation studies that summarize the available evidence for the effectiveness of behavioral healthcare programs, including programs addressing substance misuse, mental health, child welfare, or offender rehabilitation. The study determined the extent to which visitors to selected EBPRs accomplished the objectives of their visits and how often those visits resulted in the adoption of new or improved evidence-based interventions (EBIs).

METHOD

A follow-up telephone survey was conducted with 216 visitors to a convenience sample of six EBPRs an average of six months after the visitors' incident visit to the EBPR.

RESULTS

The most frequent objective was to identify evidence-based programs/services, curricula or assessments, followed by finding resources to implement or improve the preceding and writing a grant proposal including to comply with funding requirements; 71% of such objectives were achieved across the full set of objectives. Implementation of an EBI was completely achieved for 31% of relevant objectives and some progress on EBI implementation occurred for 19% of relevant objectives.

CONCLUSIONS

This is the first study to document the usage of EBPRs as a modality to increase the utilization of EBIs in the actual practice of behavioral healthcare. The results support the continued use of web-based EBPRs for disseminating information on evidence-based interventions for behavioral healthcare.

Current and emerging pharmacotherapies for opioid dependence treatments in adults: a comprehensive update

INTRODUCTION

Opioid use disorder (OUD) is characterized by compulsive opioid seeking and taking, intense drug craving, and intake of opioids despite negative consequences. The prevalence of OUDs has now reached an all-time high, in parallel with peak rates of fatal opioid-related overdoses, where 15 million individuals worldwide meet the criteria for OUD. Further, in 2020, 120,000 opioid-related deaths were reported worldwide with over 75,000 of those deaths occurring within the United States.

AREAS COVERED

In this review, we highlight pharmacotherapies utilized in patients with OUDs, including opioid replacement therapies, and opioid antagonists utilized for opioid overdoses and deterrent of opioid use. We also highlight newer treatments, such as those targeting the neuroimmune system, which are potential new directions for research given the recently established role of opioids in activating neuroinflammatory pathways, as well as over the counter remedies, including kratom, that may mitigate withdrawal.

EXPERT OPINION

To effectively treat OUDs, a deeper understanding of the current therapeutics being utilized, their additive effects, and the added involvement of the neuroimmune system are essential. Additionally, a complete understanding of opioid-induced neuronal alterations and therapeutics that target these abnormalities - including the neuroimmune system - is required to develop effective treatments for OUDs.

Variations in Definitions of Evidence-Based Interventions for Behavioral Health in Eight Selected U.S. States

BACKGROUND

U.S. state legislatures fill a vital role in supporting the use of evidence-based interventions (EBIs) through statutes and regulations (mandates).

OBJECTIVE

The study determined the terms used by selected states to describe EBIs and how those terms are defined in mandates.

RESEARCH METHODS

The mandates of eight purposely selected states were accessed and coded using the Westlaw Legal Research Database.

RESULTS

Considerable variation was found in the terms used by states to describe EBIs. Although "evidence-based" was the most frequently utilized term (60% of mandates), an additional 29 alternative terms appeared with varying frequencies. Most terms were simply mentioned, with no further definition or elaboration. When terms were further defined or elaborated, the majority were defined using numerous and different types of external sources or references. Three approaches were found in the mandates defining EBIs: "single definition," "hierarchies of evidence levels," and "best available evidence"; the states differed considerably in the approaches used in their mandates.

CONCLUSIONS

The variations in EBI-related terminology across states and within states, coupled with a lack of elaboration on the meaning of important terms and the predominant use of external rather than internal guidelines, may be a source of confusion for behavioral health provider agencies that seek direction about what constitutes an EBI. Prior studies indicate that many agencies may lack staff with the technical ability to adequately evaluate what constitutes an EBI. Thus, lack of clear guidance from official state government mandates may impede the implementation of EBIs within states.

Opioid Therapy in Cancer Patients and Survivors at Risk of Addiction, Misuse or Complex Dependency

A clinical conundrum can occur when a patient with active opioid use disorder (OUD) or at elevated risk for the condition presents with cancer and related painful symptoms. Despite earlier beliefs that cancer patients were relatively unaffected by opioid misuse, it appears that cancer patients have similar risks as the general population for OUD but are more likely to need and take opioids. Treating such patients requires an individualized approach, informed consent, and a shared decision-making model. Tools exist to help stratify patients for risk of OUD. While improved clinician education in pain control is needed, patients too need to be better informed about the risks and benefits of opioids. Patients may fear pain more than OUD, but opioids are not always the most effective pain reliever for a given patient and some patients do not tolerate or want to take opioids. The association of OUD with mental health disorders (dual diagnosis) can also complicate delivery of care as patients with mental health issues may be less adherent to treatment and may use opioids for “chemical coping” as much as for pain control.

Switzerland's Narcotics Regulation Jungle: Off-Label Use, Counterfoil Prescriptions, and Opioid Agonist Therapy in the French-Speaking Cantons

The word "narcotic" is often first associated with "illicit drugs". Yet, many "narcotic" and psychotropic substances are, in fact, medicines. Controlled medicines (CM) are products that meet the legal definition of both a "narcotic" under the Swiss Narcotics Act and of a medicine under the Therapeutic Products Act. We aim to examine how similar and how different, respectively, the implementation of CM regulations is throughout French-speaking Switzerland. Based on a legal analysis of the cantonal regulations, we conducted semi-structured interviews with cantonal pharmacists and cantonal physicians. We asked them how they perceive and implement the federal legal requirements. We find that some of these requirements have fallen into disuse, notably the federal duty to notify off-label use of CM. We observe that counterfoil prescriptions in their current paper format are a veritable data graveyard in the sense that they are not actively used to monitor or supervise the market. Moreover, we detect different conditions for opioid agonist treatment authorization. Some cantons require additional physicians' training or written commitments by the person treated. Our mapping of the CM regulation implementation can serve as a basis for cantons to review their practices.

Using a pragmatically adapted, low-cost contingency management intervention to promote heroin abstinence in individuals undergoing treatment for heroin use disorder in UK drug services (PRAISE): a cluster randomised trial

INTRODUCTION

Most individuals treated for heroin use disorder receive opioid agonist treatment (OAT)(methadone or buprenorphine). However, OAT is associated with high attrition and persistent, occasional heroin use. There is some evidence for the effectiveness of contingency management (CM), a behavioural intervention involving modest financial incentives, in encouraging drug abstinence when applied adjunctively with OAT. UK drug services have a minimal track record of applying CM and limited resources to implement it. We assessed a CM intervention pragmatically adapted for ease of implementation in UK drug services to promote heroin abstinence among individuals receiving OAT.

DESIGN

Cluster randomised controlled trial.

SETTING AND PARTICIPANTS

552 adults with heroin use disorder (target 660) enrolled from 34 clusters (drug treatment clinics) in England between November 2012 and October 2015.

INTERVENTIONS

Clusters were randomly allocated 1:1:1 to OAT plus 12× weekly appointments with: (1) CM targeted at opiate abstinence at appointments (CM Abstinence); (2) CM targeted at on-time attendance at appointments (CM Attendance); or (3) no CM (treatment as usual; TAU). Modifications included monitoring behaviour weekly and fixed incentives schedule.

MEASUREMENTS

Primary outcome: heroin abstinence measured by heroin-free urines (weeks 9-12).

SECONDARY OUTCOMES

heroin abstinence 12 weeks after discontinuation of CM (weeks 21-24); attendance; self-reported drug use, physical and mental health.

RESULTS

CM Attendance was superior to TAU in encouraging heroin abstinence. Odds of a heroin-negative urine in weeks 9-12 was statistically significantly greater in CM Attendance compared with TAU (OR=2.1; 95% CI 1.1 to 3.9; p=0.030). CM Abstinence was not superior to TAU (OR=1.6; 95% CI 0.9 to 3.0; p=0.146) or CM Attendance (OR=1.3; 95% CI 0.7 to 2.4; p=0.438) (not statistically significant differences). Reductions in heroin use were not sustained at 21-24 weeks. No differences between groups in self-reported heroin use.

CONCLUSIONS

A pragmatically adapted CM intervention for routine use in UK drug services was moderately effective in encouraging heroin abstinence compared with no CM only when targeted at attendance. CM targeted at abstinence was not effective.

TRIAL REGISTRATION NUMBER

ISRCTN 01591254.

Therapeutic Approaches to Opioid Use Disorder: What is the Current Standard of Care?

Opioid use disorder is a frequent cause of suffering to communities worldwide. Therapeutic approaches to opioid use disorder include screening, appropriate assessment and diagnosis, consideration of level of care, acute management of overdose or withdrawal, treatment with medications, psychotherapeutic approaches, and community support. People who struggle with addiction to opioids often suffer deeply from direct and indirect consequences of use. Subsequently, it is critical that all medical providers understand the appropriate treatment options for opioid use disorder. This paper provides a comprehensive overview of the therapeutic options available for treatment of this chronic disease.

New Approaches in Drug Dependence: Opioids

Purpose of Review

This article aims to provide an overview of standard and adjunctive treatment options in opioid dependence in consideration of therapy-refractory courses. The relevance of oral opioid substitution treatment (OST) and measures of harm reduction as well as heroin-assisted therapies are discussed alongside non-pharmacological approaches.

Recent Findings

Currently, recommendation can be given for OST with methadone, buprenorphine, slow-release oral morphine (SROM), and levomethadone. Heroin-assisted treatment using diamorphine shall be considered as a cost-effective alternative for individuals not responding to the afore-mentioned opioid agonists in order to increase retention and reduce illicit opioid use. The modalities of application and the additional benefits of long-acting formulations of buprenorphine should be sufficiently transferred to clinicians and the eligible patients; simultaneously methods to improve planning of actions and self- management need to be refined. Regarding common primary outcomes in research on opioid treatment, evidence of the effectiveness of adjunctive psychological interventions is scarce.

Summary

Maintaining a harm reduction approach in the treatment of opioid addiction, a larger range of formulations is available for the prescribers. Embedding the pharmacological, ideally individualized treatment into a holistic, structure-giving concept also requires a reduction of fragmentation of ancillary services available, drug policies, and treatment philosophies on a global scale.

The Role of Risk or Contributory Death Factors in Methadone-Related Fatalities: A Review and Pooled Analysis

Methadone-related deaths are characterized by a wide range of post-mortem blood concentrations, due to the high pharmacokinetic/dynamic inter-individual variability, the potential subjective tolerance state and to other risk factors or comorbidities, which might enhance methadone acute toxicity. In the present study, the association among pre-existing and external conditions and diseases and the resultant methadone death capacity have been investigated. Beside a systematic literature review, a retrospective case-control study was done, dividing cases in which methadone was the only cause of death (controls), and those with associated clinical-circumstantial (naive/non-tolerant state), pathological (pulmonary or cardiovascular diseases) or toxicological (other drugs detected) conditions. Methadone concentrations were compared between the two groups and the association with conditions/diseases was assessed by multiple linear and binomial logistic regressions. Literature cases were 139, in house 35, consisting of 22 controls and 152 cases with associated conditions/diseases. Mean methadone concentrations were 2122 ng/mL and 715 ng/mL in controls and cases respectively, with a statistically significant difference (p < 0.05). Lower methadone concentrations (by 24, 19 and 33% respectively) were detected in association with naive/non-tolerant state, pulmonary diseases and presence of other drugs, and low levels of methadone (<600 ng/mL) might lead to death in the presence of the above conditions/diseases.

"My first 48 hours out": drug users' perspectives on challenges and strategies upon release from prison

BACKGROUND

Prisoners report much higher prevalence rates of drug use and more harmful consumption patterns than the general population. People who use drugs have above-average experiences with the criminal justice system in general, and the prison system and subsequent release situations in particular. Release from prison is associated with increased mortality rates among drug users due to the risk of overdose. The EU-funded project 'My first 48 hours out' aimed to address the gaps in continuity of care for long-term drug users in prison and upon release, with a special focus on drug user's perspectives on needs and challenges upon release.

METHODS

A multi-country (Belgium, France, Germany and Portugal) qualitative study was set up to explore drug users' perceptions of drug use and risk behaviour upon prison release, experiences of incarceration and release, and strategies to avoid risks when being released. In total, 104 prisoners and recently released persons with a history of drug use participated in semi-structured interviews and focus groups discussions on these topics.

RESULTS

Respondents pointed out that there are numerous challenges for people who use drugs when released from prison. Lack of stable housing and employment support were frequently mentioned, as well as complex administrative procedures regarding access to services, health insurance and welfare benefits. Besides structural challenges, individual issues may challenge social reintegration like 'old habits', mental health problems and disrupted social networks. As a result, (ex-)prisoners adopt individual strategies to cope with the risks and challenges at release.

CONCLUSION

Measures to prepare prisoners for release often do not focus on the individual and specific challenges of persons who use drugs. Psychosocial and medical support need to be improved and adjusted to drug users' needs inside and outside prison. To improve the quality and continuity of care around release, the perspectives and coping strategies of people who use drugs should be used to better address their needs and barriers to treatment.

Medication for Adolescents and Young Adults With Opioid Use Disorder

Opioid-related morbidity and mortality have risen in many settings globally. It is critical that practitioners who work with adolescents and young adults (AYAs) provide timely, evidence-based treatment for opioid use disorder (OUD). Such treatment should include medications for opioid use disorder (MOUD), including buprenorphine, naltrexone, and methadone. Medication treatment is associated with reduced mortality, fewer relapses to opioid use, and enhanced recovery and retention in addiction care, among other positive health outcomes. Unfortunately, the vast majority of AYAs with OUD do not receive medication. The Society for Adolescent Health and Medicine recommends that AYAs be offered MOUD as a critical component of an integrated treatment approach. Barriers to receipt of medications are widespread; many are common to high-, middle-, and low-income countries alike, whereas others differ. Such barriers should be minimized to ensure equitable access to youth-friendly, affirming, and confidential addiction treatment that includes MOUD. Robust education on OUD and medication treatment should be provided to all practitioners who work with AYAs. Strategies to reduce stigma surrounding medication-and stigma experienced by individuals with substance use disorders more generally-should be widely implemented. A broad research agenda is proposed with the goal of expanding the evidence base for the use and delivery of MOUD for AYAs.

Substance use and symptoms of mental health disorders: a prospective cohort of patients with severe substance use disorders in Norway

BACKGROUND

There is high co-occurrence of substance use disorders (SUD) and mental health disorders. We aimed to assess impact of substance use patterns and sociodemographic factors on mental health distress using the ten-item Hopkins Symptom Checklist (SCL-10) over time.

METHODS

Nested prospective cohort study of 707 participants with severe SUD across nine opioid-agonist-therapy outpatient clinics and low-threshold municipality clinics in Norway, during 2017-2020. Descriptive statistics were derived at baseline and reported by means and standard deviation (SD). A linear mixed model analysis was used to assess the impact of substance use patterns and sociodemographic factors on SCL-10 sum score with beta coefficients with 95% confidence intervals (CI).

RESULTS

Mean (SD) SCL-10 score was 2.2 (0.8) at baseline with large variations across patients. We observed more symptoms of mental health disorders among people with frequent use of benzodiazepines (beta 3.6, CI:2.4;4.8), cannabis (1.3, CI:0.2;2.5), opioids (2.7, CI:1.1;4.2), and less symptoms among people using frequent stimulant use (- 2.7, CI:-4.1;-1.4) compared to no or less frequent use. Females (1.8, CI:0.7;3.0) and participants with debt worries (2.2, CI:1.1;3.3) and unstable living conditions (1.7, CI:0.0;3.3) had also higher burden of mental health symptoms. There were large individual variations in SCL-10 score from baseline to follow-up, but no consistent time trends indicating change over time for the whole group. 65% of the cohort had a mean score > 1.85, the standard reference score.

CONCLUSIONS

People with SUD have a considerable burden of mental health symptoms. We found no association between substance use patterns and change in mental health symptoms over time. This could suggest that the differences observed were indicating flattening of effects or self-medication to a larger degree than medication-related decline in mental health. This call for better individualized mental health assessment and patient care.

Unveiling the comparative efficacy and tolerability of comprehensive treatments for migraine: A protocol of systematic review and Bayesian network meta-analysis

BACKGROUND

Migraine is a chronic paroxysmal incapacitating neurological disorder, which endangers the health of human worldwide ranking as the third most prevalent medical condition. There are no comprehensive estimates of treatments for migraine. We will conduct this systematic review and Bayesian network meta-analysis (NMA) to synthesis quantitative and comparative evidence on the efficacy and tolerability of all the known pharmacological and non-pharmacological interventions for migraine.

METHOD

We will perform the systematic electronic search of the literature utilizing MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing & Allied Health (CINAHL), and PsycINFO. We will only include randomized controlled trials (RCTs) of high quality which appraise the efficacy or safety of any potential pharmacological or non-pharmacological interventions in the treatment of patients with migraine. The traditional pairwise meta-analyses will be performed to anticipate the heterogeneities and publication bias and the NMA will be conducted within a Bayesian hierarchical model framework to obtain estimates for all valuable treatments for migraine. The entire heterogeneity will be quantified by Q statistic and I2 index. Other analyses included sensitivity analyses, meta-regression, and subgroup analyses will also be conducted. The whole process will be conducted using in R-3.6.0 software.

RESULTS

This study will obtain the efficacy and tolerability of all potential treatments for migraine, aiming at providing consolidated evidence to help make the best choice of interventions. The results will be published in a peer-reviewed journal.

DISCUSSION

This Bayesian network meta-analysis may be the first attempt to quantitatively synthesize the efficacy and tolerability of all potential treatments for migraine. And this method can ensure us to fully utilize both the direct and indirect evidence as well as gain the comparative estimates displayed in the derived hierarchies. Besides, we have registered this protocol on the international prospective register of systematic review (PROSPERO) (CRD42020157278).

Mobile telephone delivered contingency management for encouraging adherence to supervised methadone consumption: feasibility study for an RCT of clinical and cost-effectiveness (TIES)

BACKGROUND

Prescription methadone or buprenorphine enables people with opioid use disorder to stop heroin use safely while avoiding withdrawal. To ensure methadone is taken as prescribed and to prevent diversion onto the illicit market, people starting methadone take their daily dose under a pharmacist's supervision. Many patients miss their daily methadone dose risking withdrawal, craving for heroin and overdose due to loss of heroin tolerance. Contingency management (CM) can improve medication adherence, but remote delivery using technology may be resource-light and cost-effective. We developed an innovative way to deliver CM by mobile telephone. Software monitors patients' attendance and supervised methadone consumption through an internet self-login at the pharmacy and sends reinforcing text messages to patients' mobile telephones. A linked system sends medication adherence reports to prescribers and provides early warning alerts of missed doses. A pre-paid debit card system provides financial incentives.

METHODS

A cluster randomised controlled trial design was used to test the feasibility of conducting a future trial of mobile telephone CM to encourage adherence to supervised methadone in community pharmacies. Each cluster (drug service/3 allied pharmacies) was randomly allocated to provide patient's presenting for a new episode of opiate agonist treatment (OAT) with either (a) mobile telephone text message CM, (b) mobile telephone text message reminders, or (c) no text messages. We assessed acceptability of the interventions, recruitment, and follow-up procedures.

RESULTS

Four drug clinics were approached and three recruited. Thirty-three pharmacists were approached and 9 recruited. Over 3 months, 173 individuals were screened and 10 enrolled. Few patients presented for OAT and high numbers were excluded due to receiving buprenorphine or not attending participating pharmacies. There was 96% consistency in recording medication adherence by self-login vs. pharmacy records. In focus groups, CM participants were positive about using self-login, the text messages, and debit card. Prescribers found weekly reporting, time saving, and allowed closer monitoring of patients. Pharmacists reported that the tablet device was easy to host.

CONCLUSION

Mobile telephone CM worked well, but a planned future trial will use modified eligibility criteria (existing OAT patients who regularly miss their methadone/buprenorphine doses) and increase the number of participating pharmacies.

TRIAL REGISTRATION

The trial is retrospectively registered, ISRCTN 58958179 .

Adapting treatment length to opioid-dependent individuals' needs and preferences: A 2-year follow-up to a 1-year study of extended-release naltrexone

BACKGROUND AND AIM

Extended-release naltrexone (XR-NTX) is an underused treatment option for opioid dependence, today only available in a few countries in the world. Although effective, safe and feasible in short-term treatment, long-term data are scarce and there is no recommendation for required treatment length. The aims of the study were to determine the perceived need of long-term XR-NTX treatment and to examine long-term treatment outcomes.

DESIGN

In this prospective cohort study, following a parent 1-year study of XR-NTX, participants received treatment with XR-NTX at their own discretion for a maximum of 104 weeks.

SETTING

Five urban, outpatient addiction clinics in Norway.

PARTICIPANTS

Opioid-dependent adults 18-60 years old (n=50) already participating in the parent study.

INTERVENTION

XR-NTX administrated as intra-muscular injections (380 mg) every 4 weeks.

MEASUREMENTS

Time in the study, use of opioids and other illicit substances, opioid craving, and treatment satisfaction reported every 4 weeks.

FINDINGS

Among 58 participants who completed the 1-year parent study, 50 chose to continue the treatment with XR-NTX. Median prolonged treatment time was 44.0 weeks (95% CI: 25.5-62.5), ranging from 8 to 104 weeks. Most participants (35, 70%) reported no relapse to opioid use during treatment while a subgroup (15, 30%) reported relapses to opioids during the study. Scores for mean treatment satisfaction and recommending treatment to others were very high (>9) and mean opioid craving score was very low (<1) on a scale ranging from 0 to 10.

CONCLUSIONS

Extended-release naltrexone (XR-NTX) was well tolerated in long-term treatment of opioid dependent individuals in Norway already in XR-NTX treatment. On average, the participants chose to continue treatment for almost 1 year beyond the initial 9 to 12 months of treatment. Participants reported high treatment satisfaction and 70% showed no relapse to opioids during the treatment period.

Systematic benefit-risk assessment for buprenorphine implant: a semiquantitative method to support risk management

BACKGROUND

Prior to approval in the European Union, a systematic benefit-risk assessment was required to compare buprenorphine implant to sublingual buprenorphine as part of the license application to the European Medicines Agency.

OBJECTIVE

The Benefit-Risk Action Team framework was used to describe the overall benefit-risk of buprenorphine implant in comparison to sublingual buprenorphine.

STUDY SELECTION/METHODS

A value tree of key benefits and risks related to the implant formulation of buprenorphine was constructed. Risk differences (RD) or reporting ORs (ROR) and corresponding 95% CIs were calculated for each outcome, along with the number needed to treat and number needed to harm. Swing weighting was assigned to outcomes and the weighted net clinical benefit (wNCB) was calculated.

FINDINGS

Key benefits assessed: reduced risk of illicit opioid use (RD=0.09, 95% CI 0.01 to 0.17), reduced risk of misuse and diversion (ROR=0.13, 95% CI 0.02 to 0.94), improved compliance and convenience (RD=0.20) and quality of life measures (RD=0.03). Key risks assessed: clinically significant implant breakage (RD=0.01, 95% CI 0.00 to 0.01), migration/missing implant (RD=0.01, 95% CI 0.00 to 0.02), infection at insertion/removal site (RD=0.08, 95% CI 0.03 to 0.12) and implant-related allergic reaction (RD=0.07, 95% CI 0.03 to 0.11). The wNCB for buprenorphine implant was 4.96, which suggests a favourable benefit-risk profile.

CONCLUSIONS

The benefit-risk profile of buprenorphine implant is considered favourable in comparison to sublingual buprenorphine, based on this semiquantitative analysis using available data. Further data from real-world use on benefits and risks should be used for ongoing monitoring of the benefit-risk profile of buprenorphine implants in the postmarketing setting.

Retrospective analysis of heroin detoxification with buprenorphine in a psychiatric hospital in Japan

AIM

We assessed the efficacy of buprenorphine replacement taper therapy in a psychiatric hospital in Japan.

METHODS

Based on the medical records, a retrospective analysis was performed to evaluate the outcomes of buprenorphine replacement taper therapy in 106 subjects with heroin dependence.

RESULTS

We found that replacement and taper therapy with buprenorphine could significantly reduce withdrawal symptoms during detoxification. In addition, the completion rate of detoxification was significantly improved and the length of hospital stay was significantly reduced relative to those who received conventional treatment without buprenorphine. However, the readmission rate increased after the introduction of detoxication therapy with buprenorphine.

CONCLUSION

The present findings suggest not only the efficacy and safety of buprenorphine replacement and taper therapy, but also the requirement for maintenance therapy for individuals with heroin dependence.

Alternatives to Arrest for Illicit Opioid Use: A Joint Criminal Justice and Healthcare Treatment Collaboration

Opioid overdoses continue to be a leading cause of death in the US. This public health crisis warrants innovative responses to help prevent fatal overdose. There is continued advocacy for collaborations between public health partners to create joint responses. The high correlation between persons with opioid use disorder who have a history of involvement in the criminal justice system is widely recognized, and allows for treatment intervention opportunities. Law enforcement-led treatment initiatives are still relatively new, with a few sparse early programs emerging almost a decade ago and only gaining popularity in the past few years. A lack of published methodologies creates a gap in the knowledge of applied programs that are effective and can be duplicated. This article seeks to outline an interagency relationship between police and healthcare that illustrates arrest is not the only option that law enforcement may utilize when encountering persons who use illicit substances. Program methods of a joint initiative between law enforcement and healthcare in a large, metropolitan area will be reviewed, supplemented with law enforcement overdose data and statistics on law enforcement treatment referrals.

Age disparities in six-month treatment retention for opioid use disorder

BACKGROUND AND AIMS

Adolescents with opioid use disorder (OUD) are an understudied and vulnerable population. We examined the association between age and six-month treatment retention, and whether any such association was moderated by medication treatment.

METHODS

In this retrospective cohort study, we used an insurance database with OUD treatment claims from 2006-2016. We examined 261,356 OUD treatment episodes in three age groups: adolescents (ages 12-17), young adults (18-25) and older adults (26-64). We used logistic regression to estimate prevalence of six-month retention before and after stratification by treatment type (buprenorphine, naltrexone, or psychosocial only). Insurance differences (commercial vs Medicaid) in medication treatment prevalence were also assessed.

RESULTS

Adolescents were less likely to be retained compared to adults (17.6 %; 95 % CI 16.5-18.7 % for adolescents; 25.1 %; 95 % CI 24.7-25.4 % for young adults; 33.3 %; 95 % CI 33.0-33.5 % for older adults). This disparity was reduced after adjusting for treatment type. For all ages, buprenorphine was more strongly associated with retention than naltrexone or psychosocial treatment. Adolescents who received buprenorphine were more than four times as likely to be retained in treatment (44.8 %; 95 % CI 40.6-49.0) compared to those who received psychosocial services (9.7 %; 95 % CI 8.8-10.8). Persons with commercial insurance were more likely to receive medication than those with Medicaid (73 % vs 36 %, (χ2 = 38,042.6, p < .001).

CONCLUSIONS

Age disparities in six-month treatment retention are strongly related to age disparities in medication treatment. Results point to need for improved implementation of medication treatment for persons with OUD, regardless of age or insurance status.

Initiation and Rapid Titration of Methadone in an Acute Care Setting for the Treatment of Opioid Use Disorder: A Case Report

BACKGROUND

Although methadone is an effective treatment for opioid use disorder, its initiation requires prescribing at a subtherapeutic dose with subsequent titration to a therapeutic dose over many weeks. Accordingly, the methadone induction period can be a challenging one for individuals and can be associated with an increased risk for ongoing illicit drug use and consequently overdose. Given its capacity for regular clinical assessments, acute care settings may offer a unique opportunity to reduce the duration of the induction period for methadone maintenance therapy.

CASE SUMMARY

We report a case of an individual who successfully completed initiation and rapid methadone titration for treatment of opioid use disorder in an acute care setting.

DISCUSSION

Utilizing divided dosing intervals and regular monitoring for toxicity, the patient received a cumulative methadone dose of 130 mg total within the first 48 hours of admission with continuation of a similar dose subsequently. No adverse events occurred over a 9-day follow-up period. The case report described here highlights the potential acute care settings may offer for the successful initiation and rapid titration of methadone for the treatment of opioid use disorder. Such an approach could significantly reduce the induction period associated with methadone maintenance therapy and its associated negative outcomes including ongoing illicit substance use and risk for overdose.

Perceptions of extended-release buprenorphine injections for opioid use disorder among people who regularly use opioids in Australia

AIMS

To examine perceptions of extended-release (XR) buprenorphine injections among people who regularly use opioids in Australia.

DESIGN

Cross-sectional survey prior to implementation. XR-buprenorphine was registered in Australia in November 2018.

SETTING

Sydney, Melbourne and Hobart. Participants A total of 402 people who regularly use opioids interviewed December 2017 to March 2018.

MEASUREMENTS

Primary outcome concerned the proportion of participants who believed XR-buprenorphine would be a good treatment option for them, preferred weekly versus monthly injections and perceived advantages/disadvantages of XR-buprenorphine. Independent variables concerned the demographic characteristics and features of current opioid agonist treatment (OAT; medication-type, dose, prescriber/dosing setting, unsupervised doses, out-of-pocket expenses and travel distance).

FINDINGS

Sixty-eight per cent [95% confidence interval (CI) = 63-73%] believed XR-buprenorphine was a good treatment option for them. They were more likely to report being younger [26-35 versus > 55 years; odds ratio (OR) = 3.16, 95% CI = 1.12-8.89; P = 0.029], being female (OR = 1.67, 95% CI = 1.04-2.69; P = 0.034), < 10 years school education (OR = 1.87, 95% CI = 1.12-3.12; P = 0.016) and past-month heroin (OR = 1.81, 95% CI = 1.15-2.85; P = 0.006) and methamphetamine use (OR = 1.90, 95% CI = 1.20-3.01; P = 0.006). Fifty-four per cent reported no preference for weekly versus monthly injections, 7% preferred weekly and 39% preferred monthly. Among OAT recipients (n = 255), believing XR-buprenorphine was a good treatment option was associated with shorter treatment episodes (1-2 versus ≥ 2 years; OR = 3.93, 95% CI = 1.26-12.22; P = 0.018), fewer unsupervised doses (≤ 8 doses past-month versus no take-aways; OR = 0.50; 95% CI = 0.27-0.93; P = 0.028) and longer travel distance (≥ 5 versus < 5 km; OR = 2.10, 95% CI = 1.20-3.65; P = 0.009). Sixty-nine per cent reported 'no problems or concerns' with potential differences in availability, flexibility and location of XR-buprenorphine.

CONCLUSIONS

Among regular opioid users in Australia, perceptions of extended-release buprenorphine as a good treatment option are associated with being female, recent illicit drug use and factors relating to the (in)convenience of current opioid agonist treatment.

Acupuncture combined with medication for opioid use disorder in adults: a protocol for systematic review and meta-analysis

INTRODUCTION

Opioid use disorder (OUD) is a worldwide health problem. Clinical trials indicated that acupuncture combined with medication is effective in OUD, however, there are different conclusions presented by previous trials. This study is designed to evaluate the efficacy and safety of acupuncture combined with medication in OUD.

METHODS AND ANALYSIS

PubMed, CENTRAL, Embase, Web of Science, CINAHL, PsycINFO, ProQuest Dissertation and Theses, AMED, OpenGrey, Clinicaltrials.gov and who.int/trialsearch will be searched in September 2019 without a language restriction. Randomised controlled trials (RCTs) and quasi-RCTs which included participants with OUD receiving acupuncture therapy combined with medication versus control group will be included in this study. Two reviewers will independently screen studies, extract data, assess risk of bias by the Cochrane risk of bias assessment tool and assess quality of evidence by Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Any disagreements will be arbitrated by the third reviewer. Data synthesis and analysis will be conducted by using RevMan V.5.3. Subgroup analyses, sensitivity analysis, meta-regression and reporting bias assessment will be conducted if necessary and appropriate.

ETHICS AND DISSEMINATION

On account of the nature of this systematic review and meta-analysis, ethical approval is not required. The results will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42019123436.

High retention in an opioid agonist therapy project in Durban, South Africa: the role of best practice and social cohesion

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.

COVID-19 and Substance Use Disorders: Recommendations to a Comprehensive Healthcare Response. An International Society of Addiction Medicine Practice and Policy Interest Group Position Paper

Coronavirus Disease 2019 (COVID-19) is escalating all over the world and has higher morbidities and mortalities in certain vulnerable populations. People Who Use Drugs (PWUD) are a marginalized and stigmatized group with weaker immunity responses, vulnerability to stress, poor health conditions, high-risk behaviors, and lower access to health care services. These conditions put them at a higher risk of COVID-19 infection and its complications. In this paper, an international group of experts on addiction medicine, infectious diseases, and disaster psychiatry explore the possible raised concerns in this issue and provide recommendations to manage the comorbidity of COVID-19 and Substance Use Disorder (SUD).

Canadian Guidelines on Opioid Use Disorder Among Older Adults

BACKGROUND

In Canada, rates of hospital admission from opioid overdose are higher for older adults (≥ 65) than younger adults, and opioid use disorder (OUD) is a growing concern. In response, Health Canada commissioned the Canadian Coalition of Seniors' Mental Health to create guidelines for the prevention, screening, assessment, and treatment of OUD in older adults.

METHODS

A systematic review of English language literature from 2008-2018 regarding OUD in adults was conducted. Previously published guidelines were evaluated using AGREE II, and key guidelines updated using ADAPTE method, by drawing on current literature. Recommendations were created and assessed using the GRADE method.

RESULTS

Thirty-two recommendations were created. Prevention recommendations: it is key to prioritize non-pharmacological and non-opioid strategies to treat acute and chronic noncancer pain. Assessment recommendations: a comprehensive assessment is important to help discern contributions of other medical conditions. Treatment recommendations: buprenorphine is first line for both withdrawal management and maintenance therapy, while methadone, slow-release oral morphine, or naltrexone can be used as alternatives under certain circumstances; non-pharmacological treatments should be offered as an integrated part of care.

CONCLUSION

These guidelines provide practical and timely clinical recommendations on the prevention, assessment, and treatment of OUD in older adults within the Canadian context.

Six-month retention and changes in quality of life and substance use from a low-threshold methadone maintenance therapy programme in Durban, South Africa

BACKGROUND

Emerging data points to a potential heroin use epidemic in South Africa. Despite this, access to methadone maintenance therapy and other evidence-based treatment options remains negligible. We aimed to assess retention, changes in substance use and quality of life after 6 months on methadone maintenance therapy provided through a low-threshold service in Durban, South Africa.

METHODS

We enrolled a cohort of 54 people with an opioid use disorder into the study. We reviewed and described baseline socio-demographic characteristics. Baseline and 6-month substance use was assessed using the World Health Organization's Alcohol Smoking and Substance Use Involvement Screening Test (ASSIST) and quality of life, using the SF-12. We compared changes at 6 months on methadone to baseline using the Wilcoxon signed rank test and paired-tests for the ASSIST and SF-12 scores, respectively. McNemar's test was used for comparisons between paired results of categorical variables relating to injecting frequency.

RESULTS

The majority of the participants were young, Black African males, with a history of drug use spanning over 10 years. Retention after 6 months was 81%. After 6 months, the median heroin ASSIST score decreased from 37 to 9 (p < 0.0001) and the cannabis ASSIST score increased from 12.5 to 21 (p = 0.0003). The median mental health composite score of the SF-12 increased from 41.4 to 48.7 (p = 0.0254).

CONCLUSIONS

Interim findings suggest high retention, significant reductions in heroin use and improvements in mental health among participants retained on methadone maintenance therapy for 6 months. Further research into longer term outcomes and the reasons contributing to these changes would strengthen recommendations for the scale-up of methadone maintenance therapy in South Africa.

Dihydrocodeine for detoxification and maintenance treatment in individuals with opiate use disorders

BACKGROUND

Medical treatment and detoxification from opiate disorders includes oral administration of opioid agonists. Dihydrocodeine (DHC) substitution treatment is typically low threshold and therefore has the capacity to reach wider groups of opiate users. Decisions to prescribe DHC to patients with less severe opiate disorders centre on its perceived safety, reduced toxicity, shorter half-life and more rapid onset of action, and potential retention of patients. This review set out to investigate the effects of DHC in comparison to other pharmaceutical opioids and placebos in the detoxification and substitution of individuals with opiate use disorders.

OBJECTIVES

To investigate the effectiveness of DHC in reducing illicit opiate use and other health-related outcomes among adults compared to other drugs or placebos used for detoxification or substitution therapy.

SEARCH METHODS

In February 2019 we searched Cochrane Drugs and Alcohol's Specialised Register, CENTRAL, PubMed, Embase and Web of Science. We also searched for ongoing and unpublished studies via ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and Trialsjournal.com. All searches included non-English language literature. We handsearched references of topic-related systematic reviews and the included studies.

SELECTION CRITERIA

We included randomised controlled trials that evaluated the effect of DHC for detoxification and maintenance substitution therapy for adolescent (aged 15 years and older) and adult illicit opiate users. The primary outcomes were abstinence from illicit opiate use following detoxification or maintenance therapy measured by self-report or urinalysis. The secondary outcomes were treatment retention and other health and behaviour outcomes.

DATA COLLECTION AND ANALYSIS

We followed the standard methodological procedures that are outlined by Cochrane. This includes the GRADE approach to appraise the quality of evidence.

MAIN RESULTS

We included three trials (in five articles) with 385 opiate-using participants that measured outcomes at different follow-up periods in this review. Two studies with 150 individuals compared DHC with buprenorphine for detoxification, and one study with 235 participants compared DHC to methadone for maintenance substitution therapy. We downgraded the quality of evidence mainly due to risk of bias and imprecision. For the two studies that compared DHC to buprenorphine, we found low-quality evidence of no significant difference between DHC and buprenorphine for detoxification at six-month follow-up (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.25 to 1.39; P = 0.23) in the meta-analysis for the primary outcome of abstinence from illicit opiates. Similarly, low-quality evidence indicated no difference for treatment retention (RR 1.29, 95% CI 0.99 to 1.68; P = 0.06). In the single trial that compared DHC to methadone for maintenance substitution therapy, the evidence was also of low quality, and there may be no difference in effects between DHC and methadone for reported abstinence from illicit opiates (mean difference (MD) -0.01, 95% CI -0.31 to 0.29). For treatment retention at six months' follow-up in this single trial, the RR calculated with an intention-to-treat analysis also indicated that there may be no difference between DHC and methadone (RR 1.04, 95% CI 0.94 to 1.16). The studies that compared DHC to buprenorphine reported no serious adverse events, while the DHC versus methadone study reported one death due to methadone overdose.

AUTHORS' CONCLUSIONS

We found low-quality evidence that DHC may be no more effective than other commonly used pharmacological interventions in reducing illicit opiate use. It is therefore premature to make any conclusive statements about the effectiveness of DHC, and it is suggested that further high-quality studies are conducted, especially in low- to middle-income countries.

Adherence to and Retention in Medications for Opioid Use Disorder Among Adolescents and Young Adults

The volatile opioid epidemic is associated with higher levels of opioid use disorder (OUD) and negative health outcomes in adolescents and young adults. Medications for opioid use disorder (MOUD) demonstrate the best evidence for treating OUD. Adherence to and retention in MOUD, defined as continuous engagement in treatment, among adolescents and young adults, however, is incompletely understood. We examined the state of the literature regarding the association of age with adherence to and retention in MOUD using methadone, buprenorphine, or naltrexone among persons aged 10-24 years, along with related facilitators and barriers. All studies of MOUD were searched for that examined adherence, retention, or related concepts as an outcome variable and included adolescents or young adults. Search criteria generated 10,229 records; after removing duplicates and screening titles and abstracts, 587 studies were identified for full-text review. Ultimately, 52 articles met inclusion criteria for abstraction and 17 were selected for qualitative coding and analysis. Younger age was consistently associated with shorter retention, although the overall quality of included studies was low. Several factors at the individual, interpersonal, and institutional levels, such as concurrent substance use, MOUD adherence, family conflict, and MOUD dosage and flexibility, appeared to have roles in MOUD retention among adolescents and young adults. Ways MOUD providers can tailor treatment to increase retention of adolescents and young adults are highlighted, as is the need for more research explaining MOUD adherence and retention disparities in this age group.

Opioid substitution therapy for people living in German prisons-inequality compared with civic sector

BACKGROUND

The above-average proportion of people with opioid use disorder living in prisons is a worldwide reality, and the need to treat these people was recognized internationally more than 20 years ago. Studies have shown that substitution therapies are best suited to treat opioid use disorder and reduce the risk of HIV and hepatitis C transmission and overdose. However, huge health inequalities exist in and outside of prison due to the different implementation of opioid substitution therapy (OST). People living in prisons are entitled to the best possible health care. This is established by the Universal Declaration of Human Rights and by the International Convention on Economic, Social and Cultural Rights. Solely the imprisonment, and not the loss of fundamental human rights, constitutes the punishment.

METHODS

A qualitative literature search using PubMed and Google Scholar was performed in order to identify relevant publications.

RESULTS

This review shows the inequality in availability of opioid substitution therapy for people living in prison compared with people outside of prison in Germany. It also gives possible reasons and evidence for this inequality, showing that continuing or initiating OST in prison is more beneficial for the health of people living in prison than abstinence-oriented treatment only.

CONCLUSION

It is important that drug use disorder is treated as a serious illness also in prison. Joint efforts are needed to provide people living in prison with the best possible treatment and to minimize the adverse effects of drug use. Therefore, with laws, policies, and programs that conform to international human rights standards, each state must ensure that people living in prison receive the same health care as people outside of prison.

Factors Influencing Buprenorphine Prescribing among Physicians in New York State

BACKGROUND

Increasing access to buprenorphine is an important strategy for curtailing the opioid epidemic. Research is needed to understand what facilitates prescribing among waivered physicians and how to increase the willingness and capacity to prescribe. This study describes prescribing patterns in a sample of buprenorphine-waivered physicians in New York (NY) in 2016 and examines factors influencing prescribing capacity among waivered providers.

METHODS

Surveys were mailed to a random sample of 300 physicians with DEA waivers to prescribe buprenorphine in NY which assessed demographics, practice characteristics, buprenorphine prescribing patterns, and barriers/facilitators to prescribing buprenorphine. Analyses include simple logistic regression to calculate the odds ratio, 95% confidence intervals, and p values, respectively, to examine differences in individual predictors among physicians that were actively prescribing buprenorphine and those that were not.

RESULTS

91 physicians responded to the survey, and 65% indicated they were currently prescribing buprenorphine. The mean patient census among physicians waivered to prescribe to 30 patients was 9.6 (SD = 9.7, median = 5), and to 100 patients, it was 60.5 (SD = 38.9, median = 72.5). Common facilitators included access to psychosocial referrals and better reimbursement, while inadequate resources, lack of time, and prior authorizations were the most common barriers.

CONCLUSIONS

In addition to increasing the number of waivered physicians, policy-makers should provide enhanced training and implementation support for waivered physicians to start prescribing and facilitate continued and expanded prescribing among those already doing so.

Comparing Canadian and United States opioid agonist therapy policies

Canada and the United States (U.S.) face an opioid use disorder (OUD) and opioid overdose epidemic. The most effective OUD treatment is opioid agonist therapy (OAT)-buprenorphine (with and without naloxone) and methadone. Although federal approval for OAT occurred decades ago, in both countries, access to and use of OAT is low. Restrictive policies and complex regulations contribute to limited OAT access. Through a non-systematic literature scan and a review of publicly available policy documents, we examined and compared OAT policies and practice at the federal (Canada vs. U.S.) and local levels (British Columbia [B.C.] vs. Oregon). Differences and similarities were noted between federal and local OAT policies, and subsequently OAT access. In Canada, OAT policy control has shifted from federal to provincial authorities. Conversely, in the U.S., federal authorities maintain primary control of OAT regulations. Local OAT health insurance coverage policies were substantively different between B.C. and Oregon. In B.C., five OAT options were available, while in Oregon, only two OAT options were available with administrative limitations. The differences in local OAT access and coverage policies between B.C. and Oregon, may be explained, in part, to the differences in Canadian and U.S. federal OAT policies, specifically, the relaxation of special federal OAT regulatory controls in Canada. The analysis also highlights the complicating contributions, and likely policy solutions, that exist within other drug policy sub-domains (e.g., the prescription regime, and drug control regime) and broader policy domains (e.g., constitutional rights). U.S. policymakers and health officials could consider adopting Canada's regulatory policy approach to expand OAT access to mitigate the harms of the ongoing opioid overdose epidemic.

Effectiveness of a Psycho-Social Intervention Aimed at Reducing Attrition at Methadone Maintenance Treatment Clinics: A Propensity Score Matching Analysis

Methadone maintenance treatment (MMT) is an important approach to address opioid dependence. However, MMT clinics usually report high attrition rates. Our previous randomized controlled trial demonstrated additional psycho-social services delivered by social workers could reduce attrition rates compared to MMT alone. This study aimed to evaluate the effectiveness of psycho-social service in a real-world context. A quasi-experimental design and propensity score matching was adopted. 359 clients were recruited from five MMT clinics in Guangzhou from July 2013 to April 2015. One 20-minute counseling session was offered to the control group after enrolment. The intervention group received six sessions of psycho-social services. The baseline characteristics were unbalanced between two arms in the original sample. After propensity score matching, 248 participants remained in the analysis. At month six, the intervention group had a lower attrition rate [intervention (39.5%) versus control (52.4%), P = 0.041], higher monthly income [monthly income of 1000 CNY or higher: intervention (55.9%) versus control (39.0%), P = 0.028)], higher detoxification intention score [full intention score: intervention (51.6%) versus control (32.5%), P = 0.012)], higher family support in MMT participation [intervention (77.9%) versus control (61.4%), P = 0.049)]. This study demonstrated that psycho-social services delivered by social workers can reduce MMT clients' attrition and improve their well-being in real-world settings.

US physicians' decision-making during buprenorphine-naloxone treatment: Conjoint analyses of dose and office visit adjustments based on patient progress

BACKGROUND

Research on how US physicians individualize buprenorphine-naloxone treatment is limited. The current study uses conjoint analysis to examine the importance of current dose, visit frequency, clinical indicators, and payment type on office visit and dose adjustments during buprenorphine-naloxone treatment.

METHODS

A national random sample of 776 US buprenorphine-prescribing physicians participated in a mailed survey between October 2015 and July 2018. The survey contained 16 patient vignettes describing: (1) current dose, (2) urine drug test (UDT) results and opioid blockade, (3) recent intravenous use, (4) visit attendance, (5) counseling adherence, (6) payment, and (7) visit schedule. Physicians rated how they would adjust office visits (0=definitely decrease to 5=no change to 10=definitely increase) and the dose (0=definitely decrease to 5=no change to 10=definitely increase). Descriptive statistics were calculated for the vignette responses. Conjoint analysis was used to estimate relative importance scores and part-worth utilities.

RESULTS

Across the vignettes, the mean response for adjusting office visits was 7.43 (SD = 1.69), indicating a tendency to increase the frequency of visits. UDT results/opioid blockade, intravenous use, and current visit schedule had the greatest importance scores for office visit adjustments. The mean response for adjusting the dose was 5.48 (SD = 1.69), corresponding with a tendency toward not changing dose. Current dose, UDT results/opioid blockade, and intravenous use had the largest importance scores for dose adjustment.

CONCLUSIONS

Physicians individualized buprenorphine-naloxone treatment in response to hypothetical patient attributes by changing visit frequency and, to a lesser extent, modifying maintenance dose, in a manner generally consistent with current practice guidelines.

Anhedonia as a key clinical feature in the maintenance and treatment of opioid use disorder

There is a critical need for research on clinical features that may influence response to treatment for opioid use disorder (OUD). Given its neurobiology and relevance to opioid use, anhedonia may be one such promising clinical feature. We identified and reviewed 11 studies that measured anhedonia in humans with OUD to characterize the current state of evidence and highlight potential implications for treatment. The majority of studies were cross-sectional, indicating higher anhedonia scores in opioid-dependent samples compared to healthy controls. Rates of participants with clinically significant anhedonia ranged from 21% to 48%. Anhedonia scores were correlated with opioid craving and use, however there are significant knowledge gaps regarding its time course and impact on treatment adherence and outcomes. Repeated assessment of anhedonia early in treatment for OUD is recommended, as it may be a unique predictor of dropout or non-response, and a potential target for behavioral and/or pharmacological intervention.

Diverse diagnostic profiles associated with prescription opioid use disorder in a nationwide sample: One crisis, multiple needs

OBJECTIVE

The opioid crisis has had devastating effects on individuals and communities, and it has rapidly increased in severity. However, we still lack nationally representative information on the diversity of comorbidity patterns among prescription opioid use disorder (P-OUD), other substance use disorders (SUDs), and psychopathology using the newest edition of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013). This impedes planning for multiple aspects of intervention, including society-wide allocation of treatment resources, program design at individual treatment centers, and personalized care to individual patients.

METHOD

To address this critical gap in information, we evaluated clinical profiles of American adults via latent class analysis in a large, recently collected epidemiological dataset that uses structured diagnostic assessment for DSM-5 psychopathology (National Epidemiologic Survey on Alcohol and Related Conditions-III; N = 36,309). Variables considered for profiles included lifetime diagnosis for multiple SUDs, various externalizing and internalizing conditions, and demographic variables. We then associated clinical profiles with demographic variables and functional impairment.

RESULTS

Comorbid psychopathology and other SUDs were common in latent classes with elevated and very high rates of P-OUD. To illustrate, alcohol use disorder rates were greater than 45%, and posttraumatic stress disorder rates were greater than 28% in classes with higher P-OUD rates. Higher P-OUD rates were associated with White/non-Hispanic and American Indian/Alaska Native populations. Relationships between P-OUD rates and functional impairment were inconsistent.

CONCLUSION

Many current treatment delivery systems are not designed to accommodate the heterogeneous profiles associated with high P-OUD rates. We provide specific suggestions for improvements to the mental health service system, individual clinical care programs, and future research approaches. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

From restrictive to more liberal: variations in moratlity among patients in opioid maintenance treament over a 12-year period

BACKGROUND

As the effect of opioid maintenance treatment (OMT) on overdose mortality varies both between and within countries, treatment programs need to be evaluated in different treatment settings and over time within settings. We evaluated variations in mortality in a national programme: from the initial rollout as restrictive and low-capacity to its gradual change into more liberal and higher-volume.

METHODS

A 12-year prospective longitudinal cohort study including all persons (n = 6871) applying for and entering OMT in Norway (1997-2009). We followed all patients until 2009 or until death. We used crude mortality rates (CMR) to calculate overdose and all-cause mortality among patients in OMT before, during and after treatment, during a 12-year time-period. We also calculated variations in overdose and all-cause mortality over the course of treatment and after treatment termination. We fitted proportional hazards models with covariates to the data.

RESULTS

OMT significantly reduces risk of mortality compared to being outside of treatment. The reduction in overdose death was most substantial during the initial phase of the Norwegian OMT-programme, still; we consistently find that overdose deaths were more than halved in all calendar-periods throughout observation. We did not find an elevated risk of overdose death in the first weeks of treatment, nor in the first weeks after treatment cessation.

CONCLUSION

In Norway, OMT reduces overall mortality. Reduction in mortality is likely dependent of both treatment delivery and characteristics of the at-risk population.

Dose Tapering Strategy for Heroin Abstinence among Methadone Maintenance Treatment Participants: Evidence from A Retrospective Study in Guangdong, China

Around half of methadone maintenance treatment (MMT) participants choose the tapering phase, however, the guidelines on tapering differ between countries and only include the tapering rate. Physicians need more evidence to guide clinical practice. We aimed to explore a specific tapering strategy to improve heroin abstinence among MMT participants. We conducted a retrospective study from 2006 to 2017 at nine MMT clinics in Guangdong, China, involving 853 participants with 961 treatment episodes. We performed two-level hierarchical logistic regression models to identify tapering phase characteristics associated with heroin abstinence. Among all treatment episodes, 419 (43.6%) were heroin abstinent. Participants who started tapering after 52 weeks, had a taper start dose of less than 60 mg and a taper ratio of less than 5%/week, while a dose reduction in 75%-89% of the tapering weeks provided the highest odds of heroin abstinence. This study highlights the need for a more gradual taper than current guidelines recommend and strongly suggests the inclusion of other tapering phase characteristics. Those who start the tapering phase later, have a lower dose of methadone, with a more gradual rate of taper, and a dose reduction in 75%-89% of the tapering phase increased the odds of heroin abstinence.

Factors Associated with Compliance among Methadone Maintenance Treatment Transfers: Evidence from Audit Records at Clinics in Guangdong, China

Methadone maintenance treatment (MMT) requires patients to intake their daily dose in person at their clinic. Therefore, transfer services are vital for patients who need temporary leave from their primary MMT clinic. However, studies have shown that transfer patients might delay return after temporary leave, leading to missed doses and putting them at risk of increased harm. In this study, we aimed to explore the transfer rates and factors associated with MMT patients who delayed return during a transfer period. In this retrospective analysis, we used audit records from the web-based management system from six MMT clinics in Guangdong, China. Multilevel logistic regression and multilevel Poisson regression analyses were used to examine the factors associated with patients who delayed return to their primary MMT clinic. A total of 459 people used the transfer system 2940 times between January 2006 and December 2016. Of those, patients delayed return to their primary MMT clinic 1199 times (40.78%). Patients who transferred regularly had poor compliance rates with MMT treatment. Those who once dropped out from and then re-enrolled in MMT were more likely to delay return. Most patients (82.71%) who used the transfer service for "work" were more likely to prolong their delay length. The findings highlight that a more flexible transfer system would minimize inconvenience to the patients.

Helpful Ingredients in the Treatment of Long-Term Substance Use Disorders: A Collaborative Narrative Study

Relatively few individuals with a substance use disorder (SUD) seek or receive treatment, and knowledge about the effective ingredients in SUD treatment, from the perspective of those who receive it, is scarce. Our study purpose was to explore the experiences of those with long-term SUDs and the aspects they found helpful during treatment and long-term recovery. Semi-structured interviews were conducted with 18 participants, each of whom had been diagnosed with a long-term SUD, and who had been abstinent for at least 5 years. A resource group of peer consultants in long-term recovery from SUDs contributed to study planning, preparation, and initial analyses. Participants preferred individualized, long-term treatment, and support from both therapists and other clients. They further acknowledged the importance of their own sense of responsibility for their treatment and recovery success. Greater focus should be placed on viewing long-term SUD as a long-term condition, similar to somatic diseases, and SUD treatment services should place greater emphasis on developing partnership care models, long-term monitoring and support, and actively engaging recovered clients in the care of others in SUD treatment.

A conceptual model for understanding post-release opioid-related overdose risk

Post-release opioid-related overdose mortality is the leading cause of death among people released from jails or prisons (PRJP). Informed by the proximate determinants framework, this paper presents the Post-Release Opioid-Related Overdose Risk Model. It explores the underlying, intermediate, proximate and biological determinants which contribute to risk of post-release opioid-related overdose mortality. PRJP share the underlying exposure of incarceration and the increased prevalence of several moderators (chronic pain, HIV infection, trauma, race, and suicidality) of the risk of opioid-related overdose. Intermediate determinants following release from the criminal justice system include disruption of social networks, interruptions in medical care, poverty, and stigma which exacerbate underlying, and highly prevalent, substance use and mental health disorders. Subsequent proximate determinants include interruptions in substance use treatment, including access to medications for opioid use disorder, polypharmacy, polydrug use, insufficient naloxone access, and a return to solitary opioid use. This leads to the final biological determinant of reduced respiratory tolerance and finally opioid-related overdose mortality. Mitigating the risk of opioid-related overdose mortality among PRJP will require improved coordination across criminal justice, health, and community organizations to reduce barriers to social services, ensure access to health insurance, and reduce interruptions in care continuity and reduce stigma. Healthcare services and harm reduction strategies, such as safe injection sites, should be tailored to the needs of PRJP. Expanding access to opioid agonist therapy and naloxone around the post-release period could reduce overdose deaths. Programs are also needed to divert individuals with substance use disorder away from the criminal justice system and into treatment and social services, preventing incarceration exposure.

Slow release oral morphine versus methadone for the treatment of opioid use disorder

OBJECTIVE

To assess the efficacy of slow release oral morphine (SROM) as a treatment for opioid use disorder (OUD).

DESIGN

Systematic review and meta-analysis of randomised controlled trials (RCTs).

DATA SOURCES

Three electronic databases were searched through 1 May 2018: the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE. We also searched the following electronic registers for ongoing trials: ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, Current Controlled Trials and the EU Clinical Trials Register.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included RCTs of all durations, assessing the effect of SROM on measures of treatment retention, heroin use and craving in adults who met the diagnostic criteria for OUD.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and assessed risk of bias. Data were pooled using the random-effects model and expressed as risk ratios (RRs) or mean differences with 95% CIs. Heterogeneity was assessed (χ2 statistic) and quantified (I2 statistic) and a sensitivity analysis was undertaken to assess the impact of particular high-risk trials.

RESULTS

Among 1315 records screened and four studies reviewed, four unique randomised trials met the inclusion criteria (n=471), and compared SROM with methadone. In the meta-analysis, we observed no significant differences between SROM and methadone in improving treatment retention (RR=0.98; 95%CI: 0.94 to 1.02, p=0.34) and heroin use (RR=0.96; 95% CI: 0.61 to 1.52, p=0.86). Craving data was not amenable to meta-analysis. Available data implied no differences in adverse events, heroin, cocaine or benzodiazepine use.

CONCLUSIONS

Meta-analysis of existing randomised trials suggests SROM may be generally equal to methadone in retaining patients in treatment and reducing heroin use while potentially resulting in less craving. The methodological quality of the included RCTs was low-to-moderate.

Suboxone Treatment and Recovery Trial (STAR-T): Study Protocol for a Randomised Controlled Trial of Opioid Medication Assisted Treatment with Adjunctive Medication Management Using Therapeutic Drug Monitoring and Contingency Management

INTRODUCTION

Opioid assisted treatment (OAT) with buprenorphine (BUP) is front-line medical maintenance intervention for illicit and prescription opioid use disorder (OUD). In many clinics, opioid medication is dispensed for several days for self-administration. This provides flexibility to the patient but may compromise the effectiveness of OAT because of nonadherence or medication diversion. OAT can be delivered as an entirely supervised intervention, but many patients discontinue treatment under this arrangement and dispensing costs may be prohibitive. An alternative is to enable patients to receive take-home doses contingent on OAT adherence guided by a medication management framework using Therapeutic Drug Monitoring (TDM) alongside negative urine drug screens (UDS) to provide evidence of abstinence. TDM is recommended to monitor adherence with BUP but it has not been applied in OAT programs and evaluation research to date.

METHODS

The Suboxone Treatment and Recovery Trial (STAR-T) is a single site, 16-week, parallel-group, randomised controlled trial. The aim of the study is to determine the effectiveness of a medication management framework including TDM and UDS to enable patients enrolled on outpatient OAT (with buprenorphine/naloxone [sublingual film formulation; BUP/NX-F; Suboxone™]) to receive stepped take-home doses. Following stabilisation during inpatient care, adult participants with illicit or prescription OUD were allocated (1:1) to receive (1) BUP/NX-F plus medication management for take-home doses based on TDM, UDS, and contingency management protocol (the experimental group) or (2) BUP/NX-F plus UDS only (treatment-as-usual, the control group). The primary outcome is the mean percentage of negative UDS over 16 weeks. The secondary outcome is treatment retention defined as completion of 16 weeks of OAT without interruption. There will be an exploratory analysis of the association between participant characteristics, clinical data, and outcomes.

CONCLUSIONS

Providing BUP/NX-F take-home doses contingent on adherence and opioid abstinence may enable OAT to be delivered flexibly and effectively.

TRIAL REGISTRATION

ISRCTN41645723 is retrospectively registered on 15/11/2015.

Integrated and differentiated methadone and HIV care for people who use drugs: a qualitative study in Kenya with implications for implementation science

Integrating methadone and HIV care is a priority in many low- and middle-income settings experiencing a growing challenge of HIV epidemics linked to injecting drug use. There is as yet little understanding of how to integrate methadone and HIV care in these settings and how such services can be implemented; such a gap reflects, in part, limitations in theorizing an implementation science of integrated care. In response, we qualitatively explored the delivery of methadone after its introduction in Kenya to understand integration with HIV care. Semi-structured interviews with people using methadone (n = 30) were supplemented by stakeholder interviews (n = 2) and participant observation in one city. Thematic analysis was used, that also drew on Mol's logic of care as an analytical framework. Respondents described methadone clinic-based care embedded in community support systems. Daily observed clinic care was challenging for methadone and stigmatizing for HIV treatment. In response to these challenges, integration evolved and HIV care differentiated to other sites. The resulting care system was acceptable to respondents and allowed for choice over locations and approaches to HIV care. Using Mol's logic of care as an analytical framework, we explore what led to this differentiation in integrated care. We explore co-production and experimentation around HIV care that compares with more limited experimentation for methadone. This experimentation is bounded by available discourses and materials. The study supports continued integration of services whilst allowing for differentiation of these models to adapt to client preferences. Co-location of integrated services must prioritize clinic organization that prevents HIV status disclosure. Our analysis fosters a material perspective for theory of implementation science and integration of services that focuses attention on local experimentation shaped by context.

Development of a Cascade of Care for responding to the opioid epidemic

Amid worsening opioid overdose death rates, the nation continues to face a persistent addiction treatment gap limiting access to quality care for opioid use disorder (OUD). Three FDA-approved medications (methadone, buprenorphine, and extended-release naltrexone) have high quality evidence demonstrating reductions in drug use and overdose events, but most individuals with OUD do not receive them. The development of a unified public health framework, such as a Cascade of Care, could improve system level practice and treatment outcomes. In response to feedback from many stakeholders over the past year, we have expanded upon the OUD treatment cascade, first published in 2017, with additional attention to prevention stages and both individual-level and population-based services to better inform efforts at the state and federal level. The proposed cascade framework has attracted considerable interest from federal agencies including the Centers for Disease Control and Prevention (CDC) and National Institute on Drug Abuse (NIDA) along with policy-makers nationwide. We have reviewed recent literature and evidence-based interventions related to prevention, identification, and treatment of individuals with OUD and modeled updated figures from the 2016 National Survey on Drug Use and Health. Many currently employed interventions (prescriber guidelines, prescription monitoring programs, naloxone rescue) address prevention of OUD or downstream complications but not treatment of the underlying disorder itself. An OUD Cascade of Care framework could help structure local and national efforts to combat the opioid epidemic by identifying key targets, interventions, and quality indicators across populations and settings to achieve these ends. Improved data collection and reporting methodology will be imperative.

An intervention trial targeting methadone maintenance treatment providers to improve clients' treatment retention in China

BACKGROUND

Service providers including doctors, nurses, and other healthcare professionals play an essential role in methadone maintenance treatment (MMT). This study evaluated the impact of an intervention targeting MMT providers on their clients' treatment retention.

METHODS

This study was conducted in 68 MMT clinics in five provinces of China with 36 clients randomly selected from each clinic. The clinics were randomized to intervention or control condition. The MMT CARE intervention started with group sessions to enhance providers' communication skills. The trained providers were encouraged to conduct individual sessions with clients to promote treatment engagement. The outcomes, which include client retention (main outcome) and their reception of provider-delivered individual sessions (process outcome), were measured over a 24-month period.

RESULTS

Significantly fewer intervention clients dropped out from MMT than control clients during the study period (31% vs. 41%; p < 0.0001). Dropout hazard was significantly lower in the intervention condition compared to the control condition (HR = 0.71, 95% CI: 0.57, 0.89). More intervention clients had individual sessions than control clients (93% vs. 70%; p < 0.0001). Having individual sessions was associated with a significantly lower dropout hazard (HR = 0.30, 95% CI: 0.23, 0.40). The intervention clients had a significantly lower dropout hazard than the control clients if they started the individual sessions during the first six months (HR = 0.68, 95% CI: 0.51, 0.90).

CONCLUSIONS

The MMT CARE intervention focusing on provider capacity building has demonstrated efficacy in reducing clients' treatment dropout. This study sheds light on MMT service improvement in China and other global community-based harm reduction programs.