1
|
Heinz A, Gutwinski S, Krausz M, Ernst G, Vogel M, Scherbaum N. [Challenges in the treatment of opioid dependence]. DER NERVENARZT 2024:10.1007/s00115-024-01691-9. [PMID: 39008087 DOI: 10.1007/s00115-024-01691-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/31/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND The number of persons using opioids has increased worldwide in the last decade, particularly the use of opioid analgesics in North America and Africa. In Germany, the prevalence of heroin addiction has remained relatively stable. METHOD Narrative review of the literature. RESULTS Opioid-assisted maintenance treatment (OMT) with the established substances methadone, levomethadone, slow-release morphine and buprenorphine is recommended as the first-line treatment for heroin dependence. The OMT reduces the use of heroin, mortality and individual suffering and improves the quality of life and physical health. A diamorphine and heroine-assisted treatment is an option for people who do not benefit from conventional OMT. An alternative to the use of diamorphine could be treatment with hydromorphone hydrochloride. The regulations on carrying out maintenance treatment in the Controlled Substances Prescription Act and the guidelines of the Federal Medical Association in Germany have been loosened based on the experiences of the COVID-19 pandemic, for example with respect to take-home prescriptions. There is an ongoing intensive discussion on how to deal with the decreasing number of outpatient clinics offering OMT. CONCLUSION The first-line treatment for opioid addiction is opioid-assisted substitution treatment, including diamorphine and heroin-assisted treatment. Long-acting depot medications and implants still play a subordinate role.
Collapse
Affiliation(s)
- Andreas Heinz
- Department of Psychiatry and Neurosciences, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
- Department of Psychiatry, University Hospital Charité, St. Hedwig Hospital Berlin, Berlin, Deutschland.
- Deutsches Zentrum für Psychische Gesundheit (DZPG), Berlin-Potsdam, Deutschland.
| | - Stefan Gutwinski
- Department of Psychiatry and Neurosciences, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
- Department of Psychiatry, University Hospital Charité, St. Hedwig Hospital Berlin, Berlin, Deutschland
| | - Michael Krausz
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Kanada
| | - Gernot Ernst
- Psychological Institute, University of Oslo, Oslo, Norwegen
- Kongsberg Hospital, Anesthesiology, Vestre Viken Hospital Trust, Kongsberg, Norwegen
| | - Marc Vogel
- Department of Addictive Disorders, Psychiatric University Clinic Basel, Basel, Schweiz
| | - Norbert Scherbaum
- LVR-Universitätsklinik Essen, Klinik für Psychiatrie und Psychotherapie, Medizinische Fakultät, Universität Duisburg-Essen, Essen, Deutschland
| |
Collapse
|
2
|
Schmitt-Koopmann C, Baud CA, Beuriot S, Junod V, Broers B, Simon O. Cantonal opioid agonist treatment authorisation systems - a mixed-method qualitative investigation. Swiss Med Wkly 2024; 154:3629. [PMID: 38885521 DOI: 10.57187/s.3629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND AND AIM In Switzerland, a cantonal authorisation is required to introduce opioid agonist treatments (OAT). We investigated and compared the terms of these cantonal OAT authorisations throughout Switzerland. The primary objective was to determine how the overseeing cantonal officials implemented and perceived the legal requirements. METHOD We started with a cross-sectional analysis of legal texts and cantonal OAT guidelines. Based on the document analysis, we conducted 26 semi-structured interviews with the cantonal officials who grant OAT authorisations. FINDINGS In most cantons (21 of 25), the OAT authorisation is specific to the person treated and must be renewed every year. Today, 21 cantons either have implemented or are implementing the same web-based software to process and manage OAT authorisation requests. Cantons have implemented diverging requirements regarding, amongst others, the involvement of third parties in OAT and the training required of prescribing physicians. Lastly, the OAT process does not seem to be a high priority for the overseeing officials. CONCLUSIONS From a legal standpoint, OAT authorisations should be straightforward, yet we found significant divergences among cantonal systems. We could not find scientific evidence that supports a given framework. We recommend harmonizing the 26 cantonal systems while reviewing the need for OAT authorisation.
Collapse
Affiliation(s)
| | - Carole-Anne Baud
- Faculty of Business and Economics, University of Lausanne, Lausanne, Switzerland
| | - Stéphanie Beuriot
- Faculty of Business and Economics, University of Lausanne, Lausanne, Switzerland
| | - Valérie Junod
- Faculty of Business and Economics, University of Lausanne, Lausanne, Switzerland
- Faculty of Law, University of Geneva, Geneva, Switzerland
| | - Barbara Broers
- Addiction Medicine, Geneva University Hospitals, Genève, Switzerland
| | - Olivier Simon
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Addiction Medicine, Lausanne University Hospital, Lausanne, Switzerland
| |
Collapse
|
3
|
Thomann J, Vogt SB, Guessoum A, Meyer M, Vogel M, Liechti ME, Luethi D, Duthaler U. Development and validation of an LC-MS/MS method for quantifying diamorphine and its major metabolites 6-monoacetylmorphine, morphine, morphine-3-glucuronide, and morphine-6-glucuronide in human plasma. J Chromatogr B Analyt Technol Biomed Life Sci 2024; 1237:124104. [PMID: 38552595 DOI: 10.1016/j.jchromb.2024.124104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 03/19/2024] [Accepted: 03/23/2024] [Indexed: 04/13/2024]
Abstract
Diamorphine, commonly known as heroin, is a semi-synthetic opioid analgesic. In the context of heroin-assisted treatment for opioid-dependent patients, diamorphine is mostly administered intravenously. However, recent attention has shifted towards intranasal administration as a better-tolerated alternative to the intravenous route. Here, we developed and validated a rapid bioanalytical method for the simultaneous quantification of diamorphine and its major metabolites 6-monoacetylmorphine, morphine, morphine-3-glucuronide, and morphine-6-glucuronide in human plasma using liquid chromatography-tandem mass spectrometry (LC-MS/MS). A straightforward protein precipitation extraction step was used for sample preparation. Chromatographic analyte separation was achieved using a Kinetex EVO C18 analytical column and a mobile phase gradient comprising an aqueous solution of ammonium hydrogen carbonate and methanol supplied with formic acid. Employing positive electrospray ionization and scheduled multiple reaction monitoring, we established a quantification range of 1-1,000 ng/mL for all analytes. Our validation results demonstrate a mean intra-assay accuracy of 91-106% and an intra-assay precision (CV) between 2 and 9% for all analytes and over three validation runs. The method exhibits a high extraction recovery (> 87%) and a negligible matrix effect (99-125%). Furthermore, no interferences with endogenous plasma compounds were detected. Lastly, we applied the method to assess the plasma concentrations of an opioid-dependent patient after the intranasal administration of diamorphine in a clinical study. In summary, we have successfully developed a rapid, highly reliable, and straightforward bioanalytical method for quantifying diamorphine and its metabolites in low amounts of clinical plasma samples.
Collapse
Affiliation(s)
- Jan Thomann
- Division of Clinical Pharmacology and Toxicology, Department of Biomedicine, University Hospital Basel, Basel, Switzerland; Division of Clinical Pharmacology and Toxicology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Severin B Vogt
- Division of Clinical Pharmacology and Toxicology, Department of Biomedicine, University Hospital Basel, Basel, Switzerland; Division of Clinical Pharmacology and Toxicology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Adrian Guessoum
- University Psychiatric Clinics Basel, University of Basel, Basel, Switzerland
| | - Maximilian Meyer
- University Psychiatric Clinics Basel, University of Basel, Basel, Switzerland
| | - Marc Vogel
- University Psychiatric Clinics Basel, University of Basel, Basel, Switzerland
| | - Matthias E Liechti
- Division of Clinical Pharmacology and Toxicology, Department of Biomedicine, University Hospital Basel, Basel, Switzerland; Division of Clinical Pharmacology and Toxicology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Dino Luethi
- Division of Clinical Pharmacology and Toxicology, Department of Biomedicine, University Hospital Basel, Basel, Switzerland; Division of Clinical Pharmacology and Toxicology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland.
| | - Urs Duthaler
- Division of Clinical Pharmacology and Toxicology, Department of Biomedicine, University Hospital Basel, Basel, Switzerland; Division of Clinical Pharmacology and Toxicology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland; Institute of Forensic Medicine, Department of Biomedical Engineering, University of Basel, Basel, Switzerland; Institute of Forensic Medicine, Health Department Basel-Stadt, Basel, Switzerland
| |
Collapse
|
4
|
Melis F, Hesse M, Eide D, Thylstrup B, Tjagvad C, Brummer JE, Clausen T. Who receives heroin-assisted treatment? A comparison of patients receiving opioid maintenance treatment in Denmark. Drug Alcohol Depend 2024; 254:111051. [PMID: 38091901 DOI: 10.1016/j.drugalcdep.2023.111051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/20/2023] [Accepted: 11/26/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND Since 2010, heroin-assisted treatment (HAT) has been one of the treatment options available to people with opioid use disorder (OUD) in Denmark. This study aimed to characterize HAT patients at treatment start and compare their individual characteristics to those of patients entering traditional opioid maintenance treatment (OMT) with methadone or buprenorphine during the same period. METHODS Patients who initiated HAT or OMT with methadone or buprenorphine in Denmark from 2010 to 2018 were included (n=6798). Multiple national registers were linked to compare treatment groups in terms of socio-demographic variables, previous OUD treatment episodes, hospital-based care, and criminal conviction history. RESULTS Nearly all HAT patients had a history of methadone treatment (91%) and half had residential treatment experience (48%). In the year previous to admission, HAT patients recorded the highest percentages of non-fatal overdoses (12%) and chronic hepatitis C diagnoses (16%), and the lowest percentages of psychiatric disorders (11%) compared to traditional OMT patients. Criminal convictions were also common: 39% of the HAT group had committed a property crime and 18% a drug-related crime the year before HAT entry. During the study period, an overall reduction in OMT enrollments for each year was recorded. The HAT proportion to the total remained fairly stable (4%-10%), while the buprenorphine proportion increased. CONCLUSIONS In Denmark, OMT patients exhibited numerous vulnerabilities at treatment start, and among the patient groups, HAT patients were the most burdened. HAT seems to reach the target group and adhere to formulated eligibility criteria.
Collapse
Affiliation(s)
- Francesca Melis
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, Norway.
| | - Morten Hesse
- Centre for Alcohol and Drug, Research Aarhus UniversityTuborgvej 164, Copenhagen, NV, 2400, Denmark.
| | - Desiree Eide
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, Norway.
| | - Birgitte Thylstrup
- Centre for Alcohol and Drug, Research Aarhus UniversityTuborgvej 164, Copenhagen, NV, 2400, Denmark.
| | - Christian Tjagvad
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, Norway.
| | - Julie Elizabeth Brummer
- Centre for Alcohol and Drug, Research Aarhus UniversityTuborgvej 164, Copenhagen, NV, 2400, Denmark.
| | - Thomas Clausen
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, Norway.
| |
Collapse
|
5
|
Krausz RM, Westenberg JN, Tai AM, Fadakar H, Seethapathy V, Mathew N, Azar P, Phillips A, Schütz CG, Choi F, Vogel M, Cabanis M, Meyer M, Jang K, Ignaszewski M. A Call for an Evidence-Based Strategy Against the Overdose Crisis. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2024; 69:5-9. [PMID: 37438926 PMCID: PMC10867411 DOI: 10.1177/07067437231188202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Affiliation(s)
- R. Michael Krausz
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jean N Westenberg
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Clinic for Addiction Medicine, University Psychiatric Clinics Basel, Basel, Switzerland
- School of Medicine, University College Cork, Cork, Ireland
| | - Andy M.Y. Tai
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Hasti Fadakar
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Faculty of Medicine, The University of Queensland, Herston, Australia
| | - Vijay Seethapathy
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Complex Pain and Addiction Services, Vancouver general Hospital, Vancouver, BC, Canada
- BC Mental Health and Substance Use Services, Provincial Health Services Authority, Vancouver, BC, Canada
| | - Nick Mathew
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Complex Pain and Addiction Services, Vancouver general Hospital, Vancouver, BC, Canada
- BC Mental Health and Substance Use Services, Provincial Health Services Authority, Vancouver, BC, Canada
| | - Pouya Azar
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Complex Pain and Addiction Services, Vancouver general Hospital, Vancouver, BC, Canada
| | - Anthony Phillips
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Christian G Schütz
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- BC Mental Health and Substance Use Services, Provincial Health Services Authority, Vancouver, BC, Canada
| | - Fiona Choi
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Marc Vogel
- Clinic for Addiction Medicine, University Psychiatric Clinics Basel, Basel, Switzerland
| | - Maurice Cabanis
- Centre for Mental Health, Klinikum Stuttgart, Stuttgart, Germany
| | - Maximilian Meyer
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Clinic for Addiction Medicine, University Psychiatric Clinics Basel, Basel, Switzerland
| | - Kerry Jang
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Martha Ignaszewski
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Complex Pain and Addiction Services, Vancouver general Hospital, Vancouver, BC, Canada
- BC Children's hospital, Children's and Adolescent Psychiatry, Vancouver, BC, Canada
| |
Collapse
|
6
|
Fox AD, Riback L, Perez-Correa A, Ohlendorf E, Ghiroli M, Behrends CN, López-Castro T. High Interest in Injectable Opioid Agonist Treatment With Hydromorphone Among Urban Syringe Service Program Participants. SUBSTANCE USE & ADDICTION JOURNAL 2024; 45:44-53. [PMID: 38258851 DOI: 10.1177/29767342231210552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
BACKGROUND Injectable opioid agonist treatment with hydromorphone (iOAT-H) is effective for persons who inject drugs (PWID) with opioid use disorder (OUD) but remains unavailable in the United States. Our objective was to determine interest in iOAT-H among syringe services program (SSP) participants. METHODS We recruited PWID with OUD from SSPs in New York City. Interest in iOAT-H was assessed on a 4-point scale. We compared participants who were and were not interested in iOAT-H regarding sociodemographic characteristics and self-reported variables (past 30 days): heroin use, public injection practices, and participation in illegal activity other than drug possession. Participants reported their preferred OUD treatment and reasons for these preferences. RESULTS Of 108 participants, most were male (69%), Hispanic (68%), and median age was 42 years. The median number of prior OUD treatment episodes was 6 (interquartile range: 2-12). Most (65%) were interested in iOAT-H. Interested participants (vs not interested) reported, over the prior 30 days, greater heroin use days (mean, 26.4 vs 22.3), injecting in public more times (median, 15 vs 6), and a higher percentage having participated in illegal activity (40% vs 16%). Preferences for OUD treatment were: iOAT-H (43%), methadone (39%), and buprenorphine (9%). Participants who preferred iOAT-H to conventional OUD treatments reported preferring injection as a route of administration and that available OUD treatments helped them insufficiently. CONCLUSIONS SSP participants with OUD reported high interest in iOAT-H. Participants had attempted conventional treatments but still used heroin almost daily. We identified PWID at risk for opioid-related harms who potentially could benefit from iOAT-H.
Collapse
Affiliation(s)
- Aaron D Fox
- Albert Einstein College of Medicine, Bronx, NY, USA
- Montefiore Medical Center, Bronx, NY, USA
| | - Lindsey Riback
- Albert Einstein College of Medicine, Bronx, NY, USA
- Montefiore Medical Center, Bronx, NY, USA
| | - Andres Perez-Correa
- Albert Einstein College of Medicine, Bronx, NY, USA
- Montefiore Medical Center, Bronx, NY, USA
| | | | - Megan Ghiroli
- Albert Einstein College of Medicine, Bronx, NY, USA
- Montefiore Medical Center, Bronx, NY, USA
| | | | | |
Collapse
|
7
|
Meyer M, Westenberg JN, Jang KL, Choi F, Schreiter S, Mathew N, King C, Lang UE, Vogel M, Krausz RM. Shifting drug markets in North America - a global crisis in the making? Int J Ment Health Syst 2023; 17:36. [PMID: 37880722 PMCID: PMC10598952 DOI: 10.1186/s13033-023-00601-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 09/27/2023] [Indexed: 10/27/2023] Open
Abstract
Understanding drug market dynamics and their underlying driving factors is paramount to developing effective responses to the overdose crisis in North America. This paper summarises the distinct drug market trends observed locally and internationally over the past decade to extrapolate future drug market trajectories. The emergence of fentanyl on North American street markets from 2014 onwards led to a shift of street drug use patterns. Previously perceived as contaminants, novel synthetic opioids became the drugs of choice and a trend towards higher potency was observed across various substance classes. The diversification of distribution strategies as well as the regionalisation and industrialisation of production followed basic economic principles that were heavily influenced by prosecution and policy makers. Particularly, the trend towards higher potency is likely most indicative of what to expect from future illicit drug market developments. Nitazenes and fentanyl-analogues, several times more potent than fentanyl itself, are increasingly detected in toxicological testing and have the potential of becoming the drugs of choice in the future. The dynamic of drug import and local production is less clear and influenced by a multitude of factors like precursor availability, know-how, infrastructure, and the success of local drug enforcement strategies. Drug market dynamics and the current trajectory towards ultrapotent opioids need to be recognised by legislation, enforcement, and the health care system to prepare effective responses. Without significant improvements in treatment access, the implementation of preventative approaches and early warning systems, the mortality rate will continue to increase. Furthermore, there is no mechanism in place preventing the currently North American focused overdose crisis to spread to other parts of the globe, particularly Europe. A system of oversight, research, and treatment is needed to address mortality rates of historic proportions and prevent further harm.
Collapse
Affiliation(s)
- Maximilian Meyer
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada.
- University Psychiatric Clinics Basel, University of Basel, Basel, Switzerland.
| | - Jean N Westenberg
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada
| | - Kerry L Jang
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada
| | - Fiona Choi
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada
| | - Stefanie Schreiter
- Department of Psychiatry and Neurosciences, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nickie Mathew
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada
| | - Conor King
- Victoria Police Department, Victoria, Canada
| | - Undine E Lang
- University Psychiatric Clinics Basel, University of Basel, Basel, Switzerland
| | - Marc Vogel
- University Psychiatric Clinics Basel, University of Basel, Basel, Switzerland
| | - R Michael Krausz
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, 5950 University Boulevard, Vancouver, BC, V6T 1Z3, Canada
| |
Collapse
|
8
|
Meyer M, Westenberg JN, Brunner P, Gürtler M, Wiesbeck GA, Lang UE, Vogel M, Dürsteler KM. Sexual dysfunction prevalence, risk factors, and help-seeking behavior in opioid agonist treatment and general psychiatry: a cross-sectional study. Front Psychiatry 2023; 14:1204236. [PMID: 37608998 PMCID: PMC10440384 DOI: 10.3389/fpsyt.2023.1204236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/25/2023] [Indexed: 08/24/2023] Open
Abstract
Background Mental disorders pose a high risk for the occurrence of sexual dysfunctions (SD). This study aimed to investigate prevalence of risk factors and help-seeking behavior for sexual dysfunctions in patients with opioid use disorder compared to patients seeking psychotherapeutic help. Methods Ninety-seven patients at two opioid agonist treatment (OAT) centers and 65 psychotherapeutic patients from a psychiatric practice (PP) in Switzerland were included in the study. Self-report assessments comprised sexual functioning (IIEF: International Index of Erectile Function; FSFI: Female Sexual Function Index), depressive state, psychological distress, alcohol consumption, nicotine use, and a self-designed questionnaire on help-seeking behavior. We used chi-squared and Mann-Whitney U tests for group comparisons and binary logistic regression models to identify variables predicting the occurrence of sexual dysfunctions. Results There was no statistically significant difference (p = 0.140) in the prevalence of SD between OAT (n = 64, 66.0%) and PP sample (n = 35, 53.8%). OAT patients scored significantly higher in scales assessing nicotine use (p < 0.001) and depressive state (p = 0.005). Male OAT patients scored significantly worse on the Erectile Function scale (p = 0.005) and female PP patients scored significantly worse on the FSFI Pain domain (p = 0.022). Opioid use disorder, higher age, and being female predicted the occurrence of SD in the total sample. In the OAT sample, only higher age remained predictive for the occurrence of SD. A lack of help-seeking behavior was observed in both groups, with only 31% of OAT patients and 35% of PP patients ever having talked about their sexual health with their treating physician. Conclusion SD are common among psychiatric patients receiving OAT and general psychiatric patients seeking psychotherapy. Professionals providing mental healthcare to patients must emphasize prevention and routine assessments of sexual functioning needs.
Collapse
Affiliation(s)
- Maximilian Meyer
- Clinic for Adult Psychiatry, University Psychiatric Clinics, University of Basel, Basel, Switzerland
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Jean N. Westenberg
- Clinic for Adult Psychiatry, University Psychiatric Clinics, University of Basel, Basel, Switzerland
| | - Patrick Brunner
- Clinic for Adult Psychiatry, University Psychiatric Clinics, University of Basel, Basel, Switzerland
| | - Martin Gürtler
- Health Center Allschwil (Gesundheitszentrum Allschwil AG), Allschwil, Switzerland
| | | | - Undine E. Lang
- Clinic for Adult Psychiatry, University Psychiatric Clinics, University of Basel, Basel, Switzerland
| | - Marc Vogel
- Clinic for Adult Psychiatry, University Psychiatric Clinics, University of Basel, Basel, Switzerland
| | - Kenneth M. Dürsteler
- Clinic for Adult Psychiatry, University Psychiatric Clinics, University of Basel, Basel, Switzerland
- Department for Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| |
Collapse
|
9
|
Kim JJ, Nikoo M, Nikoo N, Javidanbardan S, Kazemi A, Choi F, Gholami A, Lafooraki NY, Vogel M, Rezazadeh-Azar P, Meyer M, Cabanis M, Jang K, Aknondzadeh S, Krausz M. Quality of life of patients treated with opium tincture or methadone: A randomized controlled trial. Drug Alcohol Depend 2023; 249:110874. [PMID: 37402335 DOI: 10.1016/j.drugalcdep.2023.110874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/19/2023] [Accepted: 06/21/2023] [Indexed: 07/06/2023]
Abstract
OBJECTIVE Quality of life (QoL) is an increasingly recognized patient-centered treatment outcome in individuals with opioid use disorder. There is a gap in literature on the impact of opium tincture (OT) on patients' QoL compared to standard treatment options such as methadone. This study aimed to compare the QoL of participants with opioid use disorder receiving OAT using OT or methadone and identify the factors associated with their QoL during treatment. METHODS The opium trial was a multicenter non-inferiority randomized clinical trial in four private OAT outpatient clinics in Iran. The study assigned patients to either OT (10 mg/ml) or methadone sirup (5 mg/ml) for a follow-up of 85 days. QoL was assessed using the brief version of the World Health Organization Quality of Life instrument (WHOQOL- BREF). RESULTS A total of 83 participants, 35 (42.2%) in the OT arm and 48 (57.8%) in the methadone arm, completed the WHOQOL-BREF in full and were included in the primary analysis. The mean score of patients' QoL showed improvement compared to baseline, but differences were not statistically significant between OT and methadone arms (p = 0.786). Improvements were mainly observed within the first 30 days of receiving treatment. Being married and lower psychological distress were associated with an improved QoL. Within the social relationships domain, male gender showed significantly higher QoL compared to females. CONCLUSION OT shows promise as an OAT medication, comparable to methadone in improving patients' QoL. There is a need to incorporate psychosocial interventions to further sustain and improve the QoL in this population. Identifying other social determinants of health which affect QoL and the cultural adaptation of assessments for individuals from various ethnocultural backgrounds are critical areas of inquiry.
Collapse
Affiliation(s)
- Jane J Kim
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, V6T 2A1, Canada.
| | - Mohammadali Nikoo
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, V6T 2A1, Canada
| | - Nooshin Nikoo
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Alireza Kazemi
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, V6T 2A1, Canada
| | - Fiona Choi
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, V6T 2A1, Canada
| | - Ali Gholami
- Kian Methadone Maintenance Treatment Clinic, Sari, Mazandaran, Iran
| | - Neda Y Lafooraki
- Islamic Azad University, Science and Research Branch, Mazandaran, Iran
| | - Marc Vogel
- Division of Substance Use Disorders, University of Basel Psychiatric Clinics, Basel, Switzerland
| | - Pouya Rezazadeh-Azar
- Complex Pain and Addiction Services, Vancouver General Hospital & Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Maximilian Meyer
- University Psychiatric Clinics Basel, University of Basel, Basel, Switzerland
| | - Maurice Cabanis
- Center for Mental Health, Clinic for Addiction Medicine and Addictive Behavior, Klinikum Stuttgart, Stuttgart, 70374, Germany
| | - Kerry Jang
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, V6T 2A1, Canada
| | - Shahin Aknondzadeh
- Psychiatric Research Center, Roozbeh Hospital, Department of Psychiatry, Faculty of Medicine, Tehran University of Medical Sciences, Iran
| | - Michael Krausz
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, V6T 2A1, Canada
| |
Collapse
|
10
|
Arnet I, Dürsteler KM, Jaiteh C, Grossmann F, Hersberger KE. Rescue Analgesia for Opioid-Dependent Individuals on Opioid Agonist Treatment during Hospitalization: Adherence to Guideline Treatment. Eur Addict Res 2023; 29:253-263. [PMID: 37302389 PMCID: PMC10614254 DOI: 10.1159/000530266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 03/16/2023] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Opioid agonist treatment (OAT) is the first-line treatment for opioid use disorder (OUD). Simultaneously, opioids are essential medicines in acute pain management. The literature is scarce on acute pain management in individuals with OUD, and guidelines are controversial for patients on OAT. We aimed at analyzing rescue analgesia in opioid-dependent individuals on OAT during hospitalization in the University Hospital Basel, Switzerland. METHODS Patient hospital records were extracted from the database over 6 months (Jan-Jun) in 2015 and 2018. Of the 3,216 extracted patient records, we identified 255 cases on OAT with full datasets. Rescue analgesia was defined according to established principles of acute pain management, e.g., i) the analgesic agent is identical to the OAT medication, and ii) the opioid agent is dosed above 1/6th morphine equivalent dose of the OAT medication. RESULTS The patients were on average 51.3 ± 10.5 years old (range: 22-79 years), of which 64% were men. The most frequent OAT agents were methadone and morphine (34.9% and 34.5%). Rescue analgesia was not documented in 14 cases. Guideline-concordant rescue analgesia was observed in 186 cases (72.9%) and consisted mostly of NSAIDs, including paracetamol (80 cases), and identical agents such as the OAT opioid (70 cases). Guideline-divergent rescue analgesia was observed in 69 (27.1%) cases, predominantly due to an underdosed opioid agent (32 cases), another agent other than the OAT (18 cases), or contraindicated agents (10 cases). DISCUSSION Our analysis suggests that rescue analgesia in hospitalized OAT patients was predominantly concordant with guidelines, while divergent prescriptions seemed to follow common principles of pain medicine. Clear guidelines are needed to appropriately treat acute pain in hospitalized OAT patients.
Collapse
Affiliation(s)
- Isabelle Arnet
- Department of Pharmaceutical Sciences, Pharmaceutical Care Research Group, University of Basel, Basel, Switzerland
| | - Kenneth M. Dürsteler
- University Psychiatric Clinics Basel, Basel, Switzerland
- Department for Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Christine Jaiteh
- Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Florian Grossmann
- Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Kurt E. Hersberger
- Department of Pharmaceutical Sciences, Pharmaceutical Care Research Group, University of Basel, Basel, Switzerland
| |
Collapse
|
11
|
Westenberg JN, Meyer M, Strasser J, Krausz M, Dürsteler KM, Falcato L, Vogel M. Feasibility, safety, and acceptability of intranasal heroin-assisted treatment in Switzerland: protocol for a prospective multicentre observational cohort study. Addict Sci Clin Pract 2023; 18:15. [PMID: 36906604 PMCID: PMC10007841 DOI: 10.1186/s13722-023-00367-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/06/2023] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND Heroin-assisted treatment (HAT) is a proven effective treatment option for individuals with severe opioid use disorder (OUD). In Switzerland, pharmaceutical heroin (diacetylmorphine, DAM) is available in tablet form or as injectable liquid. This creates a large barrier for individuals who require the rapid onset of effect but are either unable or do not want to inject, or who primarily snort opioids. Early experimental data has demonstrated that intranasal DAM administration can be a viable alternative to the intravenous or intramuscular route of administration. The purpose of this study is to assess the feasibility, safety, and acceptability of intranasal HAT. METHODS This study will assess intranasal DAM using a prospective multicentre observational cohort study design in HAT clinics across Switzerland. Patients will be offered to switch from oral or injectable DAM to intranasal DAM. Participants will be followed-up over 3 years, with assessments at baseline, and after 4, 52, 104 and 156 weeks. The primary outcome measure (POM) is retention in treatment. Secondary outcomes (SOM) include prescriptions and routes of administration of other opioid agonists, illicit substance use, risk behaviour, delinquency, health and social functioning, treatment adherence, opioid craving, satisfaction, subjective effects, quality of life, physical health, and mental health. CONCLUSIONS The results derived from this study will generate the first major body of clinical evidence on the safety, acceptability, and feasibility of intranasal HAT. If proven to be safe, feasible and acceptable, this study would increase the accessibility of intranasal OAT for individuals with OUD globally as a critical improvement in risk reduction.
Collapse
Affiliation(s)
- Jean N Westenberg
- University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002, Basel, Switzerland.,Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,School of Medicine, University College Cork, Cork, Ireland
| | - Maximilian Meyer
- University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002, Basel, Switzerland.,Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Johannes Strasser
- University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002, Basel, Switzerland
| | - Michael Krausz
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kenneth M Dürsteler
- University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002, Basel, Switzerland.,Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zürich, Zurich, Switzerland
| | - Luis Falcato
- Arud Zentrum Für Suchtmedizin, Zurich, Switzerland
| | - Marc Vogel
- University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002, Basel, Switzerland.
| |
Collapse
|
12
|
Magel T, Matzinger E, Blawatt S, Harrison S, MacDonald S, Amara S, Metcalfe R, Bansback N, Byres D, Schechter M, Oviedo-Joekes E. How injectable opioid agonist treatment (iOAT) care could be improved? service providers and stakeholders’ perspectives. DRUGS: EDUCATION, PREVENTION AND POLICY 2023. [DOI: 10.1080/09687637.2023.2176287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
- Tianna Magel
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Elizabeth Matzinger
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul’s Hospital, Vancouver, Canada
| | - Sarah Blawatt
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul’s Hospital, Vancouver, Canada
| | - Scott Harrison
- Providence Health Care, Providence Crosstown Clinic, Vancouver, Canada
| | - Scott MacDonald
- Providence Health Care, Providence Crosstown Clinic, Vancouver, Canada
| | - Sherif Amara
- SafePoint Supervised Consumption Site, Fraser Health Authority, Surrey, Canada
| | - Rebecca Metcalfe
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul’s Hospital, Vancouver, Canada
| | - Nick Bansback
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul’s Hospital, Vancouver, Canada
| | - David Byres
- Provincial Health Services Authority, Vancouver, Canada
| | - Martin Schechter
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul’s Hospital, Vancouver, Canada
| | - Eugenia Oviedo-Joekes
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul’s Hospital, Vancouver, Canada
| |
Collapse
|
13
|
Vogel M, Meyer M, Westenberg JN, Kormann A, Simon O, Salim Hassan Fadlelseed R, Kurmann M, Bröer R, Devaud N, Sanwald U, Baumgartner S, Binder H, Strasser J, Krausz RM, Beck T, Dürsteler KM, Falcato L. Safety and feasibility of intranasal heroin-assisted treatment: 4-week preliminary findings from a Swiss multicentre observational study. Harm Reduct J 2023; 20:2. [PMID: 36611162 PMCID: PMC9826580 DOI: 10.1186/s12954-023-00731-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 01/03/2023] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Heroin-assisted treatment (HAT) is effective for individuals with severe opioid use disorder (OUD) who do not respond sufficiently to other opioid agonist treatments. It is mostly offered with injectable diacetylmorphine (DAM) or DAM tablets creating a barrier for individuals who need the rapid onset of action but are either unable or unwilling to inject, or primarily snort opioids. To explore another route of administration, we evaluated the safety and feasibility of intranasal (IN) DAM. METHODS This is a multicentre observational cohort study among patients in Swiss HAT. All patients planning to receive IN DAM within the treatment centres were eligible to participate. Participants were either completely switched to IN DAM or received IN DAM in addition to other DAM formulations or opioid agonists. Patients were followed up for four weeks. Sociodemographic characteristics, current HAT regimen, reasons for starting IN DAM, IN DAM doses, number of injection events in the sample, IN DAM continuation rate, and appearance of adverse events and nose-related problems were evaluated. RESULTS Participants (n = 52) reported vein damage, preference for nasal route of administration, and desire of a stronger effect or for a less harmful route of administration as primary reasons for switching to IN DAM. After four weeks, 90.4% of participants (n = 47) still received IN DAM. Weekly average realised injection events decreased by 44.4% from the month before IN DAM initiation to the month following. No severe adverse events were reported. CONCLUSIONS After four weeks, IN DAM was a feasible and safe alternative to other routes of administration for patients with severe OUD in HAT. It addressed the needs of individuals with OUD and reduced injection behaviour. More long-term research efforts are needed to systematically assess efficacy of and patient satisfaction with IN DAM.
Collapse
Affiliation(s)
- Marc Vogel
- University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002, Basel, Switzerland.
| | - Maximilian Meyer
- grid.6612.30000 0004 1937 0642University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002 Basel, Switzerland
| | - Jean N. Westenberg
- grid.6612.30000 0004 1937 0642University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002 Basel, Switzerland ,grid.17091.3e0000 0001 2288 9830Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC Canada
| | | | - Olivier Simon
- grid.9851.50000 0001 2165 4204Service of Addiction Medicine, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | | | - Markus Kurmann
- HeGeBe HEROL, Psychiatric Services, Hospitals Solothurn, Olten, Switzerland
| | - Rebecca Bröer
- SuGeBe Gourrama, Psychiatric Services, Hospitals Solothurn, Solothurn, Switzerland
| | | | - Ulrike Sanwald
- Integrierte Suchthilfe Winterthur ISW, Integrated Psychiatry Winterthur, Winterthur, Switzerland
| | | | - Hannes Binder
- Outpatient Clinic for Substance Use Disorders, Psychiatric Clinic Baselland, Reinach, Switzerland
| | - Johannes Strasser
- grid.6612.30000 0004 1937 0642University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002 Basel, Switzerland
| | - R. Michael Krausz
- grid.17091.3e0000 0001 2288 9830Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC Canada
| | - Thilo Beck
- grid.483175.c0000 0004 6008 5851Arud Zentrum Für Suchtmedizin, Zurich, Switzerland
| | - Kenneth M. Dürsteler
- grid.6612.30000 0004 1937 0642University of Basel Psychiatric Clinics, Wilhelm Klein-Strasse 27, 4002 Basel, Switzerland ,grid.7400.30000 0004 1937 0650Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Luis Falcato
- grid.483175.c0000 0004 6008 5851Arud Zentrum Für Suchtmedizin, Zurich, Switzerland
| |
Collapse
|
14
|
Meyer M, Westenberg JN, Strasser J, Dürsteler KM, Lang UE, Krausz M, Vogel M. Nasal administration of diacetylmorphine improved the adherence in a patient receiving heroin-assisted treatment. Harm Reduct J 2022; 19:63. [PMID: 35672825 PMCID: PMC9171487 DOI: 10.1186/s12954-022-00644-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/31/2022] [Indexed: 11/24/2022] Open
Abstract
Background Traditional heroin-assisted treatment in Switzerland consists of oral and injectable diacetylmorphine (pharmaceutical heroin) administration. To date, no suitable treatment option is available for patients who crave rapid onset (“rush”) but are either unable to inject or primarily sniff or inhale illicit heroin. We present a patient who successfully switched to intranasal heroin-assisted treatment following several unsuccessful treatment attempts. Case presentation A 29-year-old male with severe opioid use disorder, injection substance use, and concomitant cocaine use, previously prescribed slow-release oral morphine, was started on intravenous diacetylmorphine. Due to complications and harms associated with intravenous injections, nasal diacetylmorphine was prescribed. With this novel route of administration, the patient who had previously been unable to adhere to other OAT options remained in treatment. Health outcomes improved by reduction of injection-related harms, increased adherence to the heroin-assisted treatment regimen, and increased collaboration with the therapeutic staff. Conclusions Nasal heroin-assisted treatment can be a feasible therapeutic option for individuals with severe opioid use disorder who crave the fast onset of effect of diacetylmorphine but are unable to inject intravenously.
Collapse
|
15
|
Song MJ, Westenberg JN, Kianpoor K, Nikoo M, Kazemi A, Schuetz C, Jang K, Gholami A, Akhondzadeh S, Krausz M. Substance of choice, impact of heroin or opium on treatment retention in a multicentre randomised controlled trial in Iran. Drug Alcohol Rev 2022; 41:895-901. [PMID: 35170124 DOI: 10.1111/dar.13445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 12/23/2021] [Accepted: 01/13/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION In the Middle East and Asia, illicit opioid use exists across a spectrum between heroin and opium. The impact of primary opioid of choice on opioid agonist treatment retention has not been well evaluated previously, especially for opium tincture, an increasingly popular form of opioid agonist treatment in Iran. This study investigates the relationship between primary opioid of choice, namely heroin or opium, and retention in opium tincture and methadone treatment. METHODS Participants with opioid use disorder (n = 204) were randomised to receive opium tincture or methadone. All participants were categorised as mainly using opium or heroin. Bivariate analyses between treatment retention and primary opioid of choice (P < 0.05) and logistic regression were conducted. RESULTS Among the 191 participants included in this analysis, heroin was the primary substance of choice for 135 participants (70.7%) and opium for 56 (29.3%). Bivariate analysis showed that the opium group was more likely to be satisfied with family situation, employed and retained in treatment than the heroin group while less likely to experience incarceration and use multiple substances. When adjusting for covariates, primary opioid of choice was not significantly associated with retention in either methadone or opium tincture treatment arm. DISCUSSION AND CONCLUSIONS Positive factors, such as employment, housing and family support, seem to collectively explain the higher retention in treatment among those who primarily use opium compared to those who use heroin. To optimise retention in opioid agonist treatment, biopsychosocial care models should be further evaluated to improve psychosocial functioning.
Collapse
Affiliation(s)
- Michael Jae Song
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | | | - Kiana Kianpoor
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | - Mohammadali Nikoo
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | - Alireza Kazemi
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | - Christian Schuetz
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | - Kerry Jang
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | - Ali Gholami
- Kian Methadone Maintenance Treatment Clinic, Private Practice and Mazandaran University of Medical Sciences, Sari, Iran
| | - Shahin Akhondzadeh
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Michael Krausz
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| |
Collapse
|
16
|
Ferguson M, Parmar A, Papamihali K, Weng A, Lock K, Buxton JA. Investigating opioid preference to inform safe supply services: A cross sectional study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 101:103574. [PMID: 35007878 DOI: 10.1016/j.drugpo.2021.103574] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 12/17/2021] [Accepted: 12/21/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The drug toxicity crisis continues to be a significant cause of death. Over 24,600 people died from opioid toxicity in Canada over the last 5 years. Safe supply programs are required now more than ever to address the high rate of drug toxicity overdose deaths caused by illicit fentanyl and its analogues. This study aims to identify opioid preferences and associated variables to inform further phases of safe supply program implementation. METHODS The Harm Reduction Client Survey, an annual cross-sectional survey of people who use drugs (PWUD), was administered at harm reduction supply distribution sites in BC in October-December 2019. The survey collects information on substance use patterns, associated harms, stigma, and utilization of harm reduction services. Eligibility criteria for survey participation included aged 19 years or older; self-reported substance use of any illicit substance in the past six months, and ability to provide verbal informed consent. We conducted multivariate logistic regression to investigate associations with opioid preference. We used the dichotomized preference for either heroin or fentanyl as an outcome variable. Explanatory variables of interest included: geographic region, urbanicity, gender, age category, Indigenous identity, housing, employment, witnessing or experiencing an overdose, using drugs alone, using drugs at an observed consumption site, injection as preferred mode of use, injecting any drug, frequency of use, and drugs used in last 3 days. RESULTS Of the 621 survey participants, 405 reported a preferred opioid; of these 57.8% preferred heroin, 32.8% preferred fentanyl and 9.4% preferred prescription opioids. The proportion of participants who preferred heroin over fentanyl significantly increased with age. The adjusted odds of a participant 50 or older preferring heroin was 6.76 (95% CI: 2.78-16.41, p-value: < 0.01) times the odds of an individual 29 or under. The adjusted odds of an Indigenous participant reporting a preference for heroin compared to fentanyl was 1.75 (95% CI: 1.03-2.98, p-value: 0.04) the odds of a non-Indigenous participant reporting the same. Adjusted odds of heroin preference also differed between geographic regions within British Columbia, Canada. CONCLUSION Opioid preference differs by age, geographic area, and Indigenous identity. To create effective safe supply programs, we need to engage PWUD about their drugs of choice.
Collapse
Affiliation(s)
- Max Ferguson
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Amrit Parmar
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Kristi Papamihali
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Anita Weng
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kurt Lock
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Jane A Buxton
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada; Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
| |
Collapse
|
17
|
Guastaferro WP, Koetzle D, Lutgen-Nieves L, Teasdale B. Opioid Agonist Treatment Recipients within Criminal Justice-Involved Populations. Subst Use Misuse 2022; 57:698-707. [PMID: 35172673 DOI: 10.1080/10826084.2022.2034869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background: In 2014, nearly 2.5 million Americans had a substance use disorder for opioids (e.g., prescription pain medication or heroin) with over half estimated to have had prior contact with the criminal justice system. Despite strong evidence that opioid agonist treatment (OAT) is effective in reducing overdose, increasing treatment retention, and improving physical health and well-being outcomes, the use of OAT among justice-involved individuals is relatively rare. Methods: The current study uses national data of publicly funded admissions to substance abuse treatment to assess the extent to which OAT is used for cases referred to treatment by the criminal justice system. We explore the relationship between demographics, substance use severity, and access to treatment and OAT receipt. Results: Findings indicate that fewer than 6% of criminal justice cases received OAT as part of the treatment plan. Those with daily substance use, comorbid psychiatric problems, prior treatment, females, Latinos, and those who were older and those who were living independently were more likely to receive OAT, as were those living in the Northeast and with government health insurance. Conclusions: Improving the integration of the criminal justice system with substance use treatment programs would improve access to care and potentially reduce multiple health disparities faced by those in the justice system. As criminal justice responses to substance use disorder move toward a public health approach, it is imperative that the criminal justice system consider mechanisms for improving access and referrals to OAT.
Collapse
Affiliation(s)
- Wendy P Guastaferro
- School of Criminology and Criminal Justice, Florida Atlantic University, Boca Raton, Florida, USA
| | - Deborah Koetzle
- John Jay College of Criminal Justice, Criminal Justice, New York, USA
| | - Laura Lutgen-Nieves
- Department of Criminal Justice, University of Southern Indiana, Evansville, Indiana, USA
| | - Brent Teasdale
- Department of Criminal Justice Sciences, Illinois State University, Normal, IllinoisUSA
| |
Collapse
|
18
|
Vogel M, Köck P, Strasser J, Kalbermatten C, Binder H, Dürsteler KM, Walter M, Falcato L, Krausz M, Kormann A. Nasal Opioid Agonist Treatment in Patients with Severe Opioid Dependence: A Case Series. Eur Addict Res 2022; 28:80-86. [PMID: 34311466 DOI: 10.1159/000516431] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 04/09/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Opioid agonist treatment (OAT) is the first-line treatment for opioid dependence. Currently available OAT options comprise oral (methadone and morphine) and sublingual (buprenorphine) routes of administration. In Switzerland and some other countries, severely opioid-dependent individuals with insufficient response to oral or sublingual OAT are offered heroin-assisted treatment (HAT), which involves the provision of injected or oral medical heroin (diacetylmorphine [DAM]). However, many patients on treatment with injectable DAM (i-HAT) suffer from injection-related problems such as deteriorated vein status, ulcerations, endocarditis, and abscesses. Other patients who do not respond to oral OAT do not inject but snort opioids, and are not eligible for i-HAT. For this population, there is no other short-acting OAT with rapid onset of action available unless they switch to injecting, which is associated with higher risks. Nasal DAM (n-HAT) could be an alternative treatment option suitable for both populations of patients. METHODS We present a case series of 3 patients on i-HAT who successfully switched to n-HAT. RESULTS/CONCLUSIONS This is the first description of the clinical use of the nasal route of administration for HAT. n-HAT may constitute an important risk-reduced rapid-onset alternative to i-HAT. In particular, it may be suited for patients with injection-related complications, or noninjecting opioid-dependent patients failing to respond to oral OAT.
Collapse
Affiliation(s)
- Marc Vogel
- Division of Substance Use Disorders, Psychiatric Clinic, Psychiatric Services of Thurgovia, Münsterlingen, Switzerland.,University of Basel Psychiatric Clinics, Basel, Switzerland
| | - Patrick Köck
- University of Basel Psychiatric Clinics, Basel, Switzerland
| | | | | | | | | | - Marc Walter
- University of Basel Psychiatric Clinics, Basel, Switzerland
| | - Luis Falcato
- Arud Center for Addiction Medicine, Zurich, Switzerland
| | - Michael Krausz
- Institute of Mental Health, Department of Psychiatry, The University of British Columbia, Vancouver, British Columbia, Canada
| | | |
Collapse
|
19
|
Physician Communication in Injectable Opioid Agonist Treatment: Collecting Patient Ratings With the Communication Assessment Tool. J Addict Med 2021; 14:480-488. [PMID: 32032213 DOI: 10.1097/adm.0000000000000631] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Patient ratings of physician communication in the setting of daily injectable opioid agonist treatment are reported. Associations between communication items and demographic, health, drug use, and treatment characteristics are explored. METHODS Participants (n = 121) were patients receiving treatment for opioid use disorder with hydromorphone (an opioid analgesic) or diacetylmorphine (medical grade heroin). Ratings of physician communication were collected using the 14-item Communication Assessment Tool. Items were dichotomized and associations were explored using univariate and multivariable logistic regression models for each of the 14 items. RESULTS Ratings of physician communication were lower than reported in other populations. In nearly all of the 14 multivariable models, participants with more physical health problems and with lower scores for treatment drug liking had lower odds of rating physician communication as excellent. CONCLUSIONS In physician interactions with patients with opioid use disorder, there is a critical need to address comorbid physical health problems and account for patient medication preferences. PRACTICE IMPLICATIONS Findings reinforce the role physicians can play in communicating with patients about their comorbid conditions and about medication preferences. In the patient-physician interaction efforts to meet patients' evolving treatment needs and preferences can be made by offering patients access to all available evidence-based treatments.
Collapse
|
20
|
Busch M, Klein C, Uhl A, Haltmayer H, Cabanis M, Westenberg JN, Vogel M, Krausz RM. Retention in the Austrian opioid agonist treatment system: a national prospective cohort study. Harm Reduct J 2021; 18:25. [PMID: 33627159 PMCID: PMC7903033 DOI: 10.1186/s12954-021-00473-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/11/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Retention in care is a prerequisite for successful recovery, especially for a chronic condition like opioid dependence. Though retention varies greatly depending on the different substitution medication and treatment model, treatment retention is used as an indicator of treatment quality and effectiveness of care on a system and individual level. To monitor the overall quality of the Austrian opioid agonist treatment (OAT) system and to monitor patient satisfaction within the system, a new online-based registry called "eSuchmittel" was introduced in Austria at the beginning of 2011. The objective of this study is to analyze retention rates within the Austrian treatment system and to identify patient characteristics associated with retention, using data collected by the substitution registry. METHODS The complete Austrian sample of 4778 registered patients starting treatment between 1.1.2011 to 31.12.2012 were included in the prospective cohort study using data from the Austrian substitution registry. For the statistical analysis, multivariate Cox Regression and Kaplan-Meier survival analysis were used to evaluate retention in treatment. RESULTS The retention rate of the total cohort after two years was around 61%. Retention rates were significantly lower for men (exp(B) = .806, 95% CI 0.714-0.908) and significantly higher for patients aged 30 and older (exp(B) = 1.155, 95% CI 1.044-1.279), among patients located in Vienna (exp(B) = 1.439, 95% CI 1.273-1.626) and among patients prescribed oral slow-release morphine (SROM) (exp(B) = 2.141, 95% CI 1.885-2.430). CONCLUSIONS Average retention in the Austrian system is high in comparison to international retention rates. Nationally, SROM demonstrates higher treatment retention when compared to other available substitution medications. Sociodemographic and regional indicators also contribute to higher retention in care. A systematic monitoring of retention rates within a national registry is an important tool helping to evaluate the quality of care. In this study, the Austrian OAT system proves very high retention in care, an important success criterion.
Collapse
Affiliation(s)
- Martin Busch
- Gesundheit Österreich GmbH (GÖG), Vienna, Austria
| | | | - Alfred Uhl
- Gesundheit Österreich GmbH (GÖG), Vienna, Austria
- Sigmund Freud University, Vienna, Austria
| | | | - Maurice Cabanis
- Zentrum Für Seelische Gesundheit, Klinikum Stuttgart, Stuttgart, Germany
| | - Jean Nicolas Westenberg
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
- Addictions and Concurrent Disorders Research Group, Institute of Mental Health, University of British Columbia, David Strangway Building, 5950 University Boulevard, Vancouver, BC V6T 1Z3 Canada
| | - Marc Vogel
- Psychiatrische Klinik Münsterlingen, Münsterlingen, Switzerland
| | - R. Michael Krausz
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| |
Collapse
|
21
|
Ivsins A, Boyd J, Mayer S, Collins A, Sutherland C, Kerr T, McNeil R. "It's Helped Me a Lot, Just Like to Stay Alive": a Qualitative Analysis of Outcomes of a Novel Hydromorphone Tablet Distribution Program in Vancouver, Canada. J Urban Health 2021; 98:59-69. [PMID: 33118145 PMCID: PMC7592642 DOI: 10.1007/s11524-020-00489-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2020] [Indexed: 12/16/2022]
Abstract
North America is experiencing an overdose crisis driven by fentanyl, related analogues, and fentanyl-adulterated drugs. In response, there have been increased calls for "safe supply" interventions based on the premise that providing a safer alternative (i.e., pharmaceutical drugs of known quality/quantity, non-adulterated, with user agency in consumption methods) to the street drug supply will limit people's use of fentanyl-adulterated drugs and reduce overdose events. This study examined outcomes of a hydromorphone tablet distribution program intended to prevent overdose events among people who use drugs (PWUD) at high risk of fatal overdose. Semi-structured qualitative interviews were conducted with 42 people enrolled in the hydromorphone distribution program. Additionally, over 100 h of ethnographic observation were undertaken in and around the study site. Transcripts were coded using NVivo and based on categories extracted from the interview guides and those identified during initial interviews and ethnographic fieldwork. Analysis focused on narratives around experiences with the program, focusing on program-related outcomes. Our analysis identified the following positive outcomes of being enrolled in the hydromorphone tablet distribution program: (1) reduced street drug use and overdose risk, (2) improvements to health and well-being, (3) improvements in co-management of pain, and (4) economic improvements. Our findings indicate that the hydromorphone distribution program not only is effective in responding to the current overdose crisis by reducing people's use of illicit drugs but also addresses inequities stemming from the intersection of drug use and social inequality. Safe supply programs should be further implemented and evaluated in both urban and rural setting across North America as a strategy to reduce exposure to the toxic drug supply and fatal overdose.
Collapse
Affiliation(s)
- Andrew Ivsins
- British Columbia Centre on Substance Use, 1045 Howe St Suite 400, Vancouver, British Columbia, V6Z 2A9, Canada
- Department of Medicine, University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, British Columbia, V6T 1Z3, Canada
| | - Jade Boyd
- British Columbia Centre on Substance Use, 1045 Howe St Suite 400, Vancouver, British Columbia, V6Z 2A9, Canada
- Department of Medicine, University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, British Columbia, V6T 1Z3, Canada
| | - Samara Mayer
- British Columbia Centre on Substance Use, 1045 Howe St Suite 400, Vancouver, British Columbia, V6Z 2A9, Canada
| | - Alexandra Collins
- Brown University School of Public Health, 121 S Main St, Providence, RI, 02903, USA
| | - Christy Sutherland
- British Columbia Centre on Substance Use, 1045 Howe St Suite 400, Vancouver, British Columbia, V6Z 2A9, Canada
- PHS Community Services, 9 E Hastings St, Vancouver, British Columbia, V6A 1M9, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, 1045 Howe St Suite 400, Vancouver, British Columbia, V6Z 2A9, Canada
- Department of Medicine, University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, British Columbia, V6T 1Z3, Canada
| | - Ryan McNeil
- British Columbia Centre on Substance Use, 1045 Howe St Suite 400, Vancouver, British Columbia, V6Z 2A9, Canada.
- Department of Medicine, University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, British Columbia, V6T 1Z3, Canada.
- Program in Addiction Medicine, Yale School of Medicine, 333 Cedar St, New Haven, CT, 06510, USA.
- General Internal Medicine, Yale School of Medicine, 333 Cedar St, New Haven, CT, 06510, USA.
| |
Collapse
|
22
|
Krausz MR, Wong JSH, Moazen-Zadeh E, Jang KL. Been There, Done That: Lessons from Vancouver's Efforts to Stem the Tide of Overdose Deaths. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2020; 65:377-380. [PMID: 32174152 PMCID: PMC7265609 DOI: 10.1177/0706743720912860] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Michael R Krausz
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - James S H Wong
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ehsan Moazen-Zadeh
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kerry L Jang
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
23
|
Affiliation(s)
- Caroline Mitchell
- Academic Unit of Primary Medical Care, Faculty of Medicine, Dentistry and Health, University of Sheffield, Sheffield, UK
| | | | - Kenneth M Dürsteler
- Center for Addictive Disorders, University of Basel Psychiatric Hospital, Basel, Switzerland
- University Hospital of Psychiatry Zurich, Department for Psychiatry, Psychotherapy and Psychosomatics, Centre for Addictive Disorders, Zurich, Switzerland
| |
Collapse
|
24
|
Marchand K, Foreman J, MacDonald S, Harrison S, Schechter MT, Oviedo-Joekes E. Building healthcare provider relationships for patient-centered care: A qualitative study of the experiences of people receiving injectable opioid agonist treatment. Subst Abuse Treat Prev Policy 2020; 15:7. [PMID: 31959189 PMCID: PMC6971856 DOI: 10.1186/s13011-020-0253-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 01/13/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Injectable opioid agonist treatment (iOAT) was designed as a pragmatic and compassionate approach for people who have not benefitted from medication assisted treatment with oral opioids (e.g., methadone). While, a substantial body of clinical trial evidence has demonstrated the safety and effectiveness of iOAT, considerably less is known about the patient-centered aspects of this treatment and their role in self-reported treatment goals and outcomes. The aim of this study was to explore participants' experiences in iOAT as they broadly relate to the domains of patient-centered care. A secondary goal was to explore how these experiences affected participants' self-reported treatment outcomes. METHODS A qualitative methodology, and constructivist grounded theory approach, was used to guide sampling, data collection and analysis. A total of 30 in-depth interviews were conducted with people receiving iOAT in North America's first clinic. Audio-recordings for each semi-structured interview were transcribed and read repeatedly. The strategy of constant comparison was used through iterative stages of line-by-line, focused and theoretical coding until theoretical saturation was achieved. RESULTS "Building healthcare provider relationships for patient-centered care in iOAT" was the emergent core concept. Healthcare provider relationships were established through two interrelated processes: 'Opening up' was attributed to the positive environment, and to feeling understood and supported by healthcare providers. 'Being a part of care' emerged as participants felt safe to ask for what was needed and had opportunities to collaborate in treatment decisions. These processes established a foundation in which participants experienced care that was responsive to their individual dose, health and psychosocial needs. CONCLUSIONS The core concept suggested that therapeutic relationships were fundamental to experiences of patient-centered care in iOAT. When relationships were respectful and understanding, participants received individualized and holistic care in iOAT. These findings offer a valuable example of how therapeutic relationships can be strengthened in other substance use treatment settings, particularly when responding to the diverse treatment needs of clients.
Collapse
Affiliation(s)
- Kirsten Marchand
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada.
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada.
| | - Julie Foreman
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings St, Vancouver, BC, V6B 1G6, Canada
| | - Scott MacDonald
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings St, Vancouver, BC, V6B 1G6, Canada
| | - Scott Harrison
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings St, Vancouver, BC, V6B 1G6, Canada
| | - Martin T Schechter
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada
| | - Eugenia Oviedo-Joekes
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada
| |
Collapse
|
25
|
Soyka M, Pogarell O. Neue Slow-release-Buprenorphinformulierungen zur Optimierung der Opioidsubstitution. DER NERVENARZT 2019; 90:932-937. [DOI: 10.1007/s00115-019-0783-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
26
|
Ambulante Suchtmaßnahmen in der Schweiz: eine Alternative zum deutschen geschlossenen Maßregelvollzug nach § 64? FORENSISCHE PSYCHIATRIE, PSYCHOLOGIE, KRIMINOLOGIE 2019. [DOI: 10.1007/s11757-019-00541-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
|