Evaluating the impact of methadone maintenance programmes on mortality due to overdose and aids in a cohort of heroin users in Spain

Life expectancy and years of potential life lost in people with mental disorders: a systematic review and meta-analysis

Background

Mental disorders are associated with premature mortality. There is increasing research examining life expectancy and years-of-potential-life-lost (YPLL) to quantify the disease impact on survival in people with mental disorders. We aimed to systematically synthesize studies to estimate life expectancy and YPLL in people with any and specific mental disorders across a broad spectrum of diagnoses.

Methods

In this systematic review and meta-analysis, we searched Embase, MEDLINE, PsychINFO, WOS from inception to July 31, 2023, for published studies reporting life expectancy and/or YPLL for mental disorders. Criteria for study inclusion were: patients of all ages with any mental disorders; reported data on life expectancy and/or YPLL of a mental-disorder cohort relative to the general population or a comparison group without mental disorders; and cohort studies. We excluded non-cohort studies, publications containing non-peer-reviewed data or those restricted to population subgroups. Survival estimates, i.e., life expectancy and YPLL, were pooled (based on summary data extracted from the included studies) using random-effects models. Subgroup analyses and random-effects meta-regression analyses were performed to explore sources of heterogeneity. Risk-of-bias assessment was evaluated using the Newcastle-Ottawa Scale. This study is registered with PROSPERO (CRD42022321190).

Findings

Of 35,865 studies identified in our research, 109 studies from 24 countries or regions including 12,171,909 patients with mental disorders were eligible for analysis (54 for life expectancy and 109 for YPLL). Pooled life expectancy for mental disorders was 63.85 years (95% CI 62.63-65.06; I2 = 100.0%), and pooled YPLL was 14.66 years (95% CI 13.88-15.98; I2 = 100.0%). Disorder-stratified analyses revealed that substance-use disorders had the shortest life expectancy (57.07 years [95% CI 54.47-59.67]), while neurotic disorders had the longest lifespan (69.51 years [95% CI 67.26-71.76]). Substance-use disorders exhibited the greatest YPLL (20.38 years [95% CI 18.65-22.11]), followed by eating disorders (16.64 years [95% CI 7.45-25.82]), schizophrenia-spectrum disorders (15.37 years [95% CI 14.18-16.55]), and personality disorders (15.35 years [95% CI 12.80-17.89]). YPLLs attributable to natural and unnatural deaths in mental disorders were 4.38 years (95% CI 3.15-5.61) and 8.11 years (95% CI 6.10-10.13; suicide: 8.31 years [95% CI 6.43-10.19]), respectively. Stratified analyses by study period suggested that the longevity gap persisted over time. Significant cross-study heterogeneity was observed.

Interpretation

Mental disorders are associated with substantially reduced life expectancy, which is transdiagnostic in nature, encompassing a wide range of diagnoses. Implementation of comprehensive and multilevel intervention approaches is urgently needed to rectify lifespan inequalities for people with mental disorders.

Funding

None.

Treatment with Antiviral Drugs Will Significantly Inhibit the HIV-1 RNA POL Gene Expression and Viral Load in AIDS Patients

Objective

This study is to investigate the difference in HIV-1 RNA pol gene expression in AIDS patients before and after antiviral treatment and its effect on the expression level of CD4+/CD8+ T cells in peripheral blood.

Methods

The participants included 200 AIDS patients who had undergone antiviral medication, and the quantity of HIV-1 RNA pol gene was determined using nested polymerase chain reaction (nPCR). The levels of CD3+, CD4+, and CD8+ T lymphocytes in peripheral blood were measured by flow cytometry before and after therapy. The receiver operating characteristics (ROC) curve was used to assess the impact of HIV-1 RNA pol gene expression and the CD4+/CD8+ ratio on the prognosis of AIDS patients.

Results

After three months of therapy, the levels of HIV-1 RNA and viral load in the patients showed a drastic decline, while the levels of CD4+/CD8+ were markedly elevated (P < 0.05). Logistic analysis revealed that patients' viral loads were positively correlated with HIV-1 RNA and negatively correlated with CD4+/CD8+ (P < 0.05). The alanine aminotransferase (ALT), white blood cell (WBC) count, Serum creatinine (Cr), total cholesterol (TC), triglyceride (TG), and platelet (PLT) levels significantly increased following a 24-month therapy, while no significant changes were observed in the level of aspartate aminotransferase (AST), red blood cell (RBC), and neutrophil (NEU) (%). (P > 0.05).

Conclusion

Antiviral drugs significantly inhibit the HIV-1 RNA POL gene expression and viral load in AIDS patients but upregulate the expression level of CD4+/CD8+ T cells in peripheral blood.

Malmö Treatment Referral and Intervention Study (MATRIS)-36-month follow-up on retention and substance use among patients referred from needle exchange to opioid agonist treatment-The role of stimulant use at baseline

INTRODUCTION

Opioid use disorder (OUD) is the leading cause of overdose morbidity and mortality globally. Retention in opioid agonist treatment (OAT) is crucial as it effectively reduces overdose mortality among individuals suffering from OUD. Previous research on treatment retention among heroin-dependent individuals referred from needle exchange programs (NEP) to OAT is scarce, and with predictors for retention in OAT being somewhat inconclusive, further investigations into this subject is of great interest. The aim of our study was to assess 36-month treatment outcomes-defined as retention and illicit drug abstinence-and predictors of OAT discontinuation.

METHODS

This is a longitudinal cohort study of 71 study subjects successfully referred from a NEP to OAT. Participants were included between October 2011 and April 2013 and followed for 36 months. The study collected data from a structured baseline interview and from patient records, including laboratory data.

RESULTS

At the 36-month follow-up, retention was 51 % (n = 36), with mean days in treatment of 422 for those who discontinued treatment. Amphetamine use during the 30 days before inclusion was positively correlated with treatment discontinuation (AOR 1.22 [95 % CI 1.02-1.46]). No statistically significant association with retention was seen for gender, age, suicide attempt prior to treatment, or benzodiazepine use during 30 days prior to treatment. Opiate use and use of other substances were reduced over time, with major reductions occurring during the first 6 months.

CONCLUSIONS

Hitherto, baseline factors predicting retention in OAT have been insufficiently demonstrated. Active referral from NEP to OAT is effective when it comes to long-term retention and reduction of substance use while in treatment. Except from use of amphetamine, the use of other substances prior to OAT was not associated with treatment discontinuation. Further and in-depth analyses of baseline predictors are of importance for OAT retention.

Development of a β-cyclodextrin-modified gold nanoparticle-assisted electromembrane extraction method followed by capillary electrophoresis for methadone determination in plasma

In this study, gold nanoparticles (AuNPs) modified with β-cyclodextrin (β-CD) were used to assist with electromembrane extraction (EME) and were coupled with capillary electrophoresis (CE) and ultraviolet (UV) detection (CE-UV) for the extraction and measurement of methadone from plasma samples. A β-CD-modified AuNP-reinforced hollow fiber (HF) was utilized in this work. The β-CD-modified AuNPs act as an absorbent and provide an extra pathway for the analyte extraction. For obtaining the effect of the presence of β-CD-modified AuNPs in the HF pores, the extraction efficiency of the EME and β-CD-modified AuNPs/EME techniques were compared. Different parameters influencing the extraction efficacy of the EME and β-CD-modified AuNPs/EME methods were optimized. Optimal extractions were performed with 1-octanol as the organic solvent in the supported liquid membrane (SLM), with an applied voltage of 10 V as the driving force across the SLM, and with pH 7.0 in the donor solutions with a stirring speed of 1000 rpm after 20 min and 25 min for the β-CD-modified AuNPs/EME and EME methods, respectively. Under optimal conditions, compared with the EME method, the β-CD-modified AuNPs/EME method exhibited increased extraction efficacy in a short time. The β-CD-modified AuNPs/EME technique demonstrated a lower limit of detection (5.0 ng mL^-1), higher extraction recovery (68%), and a more optimal preconcentration factor (135). Furthermore, this method was successfully utilized for measuring methadone in real plasma samples.

The impact of the COVID-19 pandemic on harm reduction services in Catalonia: the experience of people who use drugs and harm reduction professionals

BACKGROUND

Harm reduction services and professionals have had to reorganise and adapt to COVID-19 prevention measures while still ensuring health and social services for people who use drugs (PUD).

OBJECTIVE

To assess the impact of the COVID-19 pandemic on PUD and on the professionals who provide harm reduction services.

METHODS

A qualitative, exploratory, multicentre design was used. Two focus groups were held with harm reduction professionals, and 40 individual semi-structured interviews were undertaken with PUD in various harm reduction services in Catalonia. Interviews and focus group discussions were transcribed and analysed using thematic content analysis.

RESULTS

Harm reduction services adapted to the pandemic situation by employing methods such as reducing opening hours and closing drop in areas, along with health protection measures such as access control, which in turn led to stress among both professionals and service users. Despite the changes implemented, PUD continued to have access to sterile drug use equipment and methadone treatment. In addition, those who were not in treatment were able to access it rapidly. Regarding their emotional state, the PUD reported that it was worse during the pandemic than before the lockdown, with women affected to a greater extent than men. The harm reduction professionals reported difficulties in managing service users' compliance with the security measures at the beginning of the lockdown and having had to focus primarily on providing food and shelter for the PUD.

CONCLUSIONS

It is important to keep PUD in mind and maintain a harm reduction perspective when implementing confinement measures in situations such as those experienced during the COVID pandemic. Guaranteeing that PUD have their basic needs such as food, hygiene and shelter covered is key.

Gender differences among persons entering medication treatment for opioid use disorder in the community

BACKGROUND AND OBJECTIVES

We evaluated gender differences among persons initiating medications for opioid use disorder (MOUD).

METHODS

Analyses of baseline assessments for a study evaluating the impact of MOUD on outcomes included: demographics, DSM-5 diagnoses, depression severity, quality of life (QoL), and medication history (N = 125).

RESULTS

When compared to men, women had a greater prevalence of generalized anxiety and posttraumatic stress disorders; and worse psychological QoL. Women were less likely to be prescribed psychiatric medications.

DISCUSSION AND CONCLUSIONS

Women may benefit from tailored multidisciplinary programs with MOUD.

SCIENTIFIC SIGNIFICANCE

This study identified that women with OUD seeking MOUD in the community had greater sedative hypnotic nonprescribed medication use and psychiatric comorbidity than men, all of which can contribute to poorer retention on MOUD and higher risk of morbidity and mortality. Thus, concurrent psychiatric disorder screening and treatment integrated with MOUD may improve retention on MOUD, opioid relapse and overdose for women.

Healthcare seeking among Swedish patients in opioid substitution treatment - a mixed methods study on barriers and facilitators

BACKGROUND

Patients in opioid substitution treatment (OST) have poorer health than the general population. Thus, they do not seek somatic health care to the extent that is medically motivated. Barriers hindering patients from seeking medical help through the conventional healthcare system result in a high degree of unmet healthcare needs. Barriers to, and facilitators of, OST patients' healthcare seeking have been sparsely examined.

METHODS

Mixed methods were employed. The quantitative part consisted of a cross-sectional questionnaire covering questions on physical health, healthcare seeking, and barriers thereof, which was collected from 209 patients in OST. A sub-sample of eleven OST patients participated in semi-structured interviews, for the qualitative part of the study, covering experience of healthcare, lifestyle, and self-images, expectations, and ideals of Swedish healthcare.

RESULTS

Confirmed by qualitative data, quantitative data revealed deprioritization, fear of stigma and of being treated badly, and problems in navigation throughout the healthcare system, leading to unsuccessful establishment of contact, being most common reasons for not seeking somatic healthcare. Thus, interviewees provided a deeper knowledge of the barriers stigma, lack of means to prioritize health and difficulties navigating throughout the healthcare system, leading to resignation and deprioritization. On-site primary healthcare (PHC) seemed to contribute to increased access and utilization of healthcare.

CONCLUSION

Individual and structural barriers decreasing access to healthcare lead to increased inequalities in healthcare utilization, adding to an already deteriorating health of this ageing population. Integration of on-site primary healthcare and OST could provide acceptable and accessible healthcare.

Substance Use, Hospitalizations, and Co-Occurring Disorders among Patients Transferred from a Needle Exchange Program to Opioid Maintenance Treatment

Opioid use disorders (OUD) is a relapsing condition with high mortality. Opioid maintenance treatment (OMT) reduces heroin use, and overall morbidity and mortality. The prevalence of psychiatric and substance use disorders, potential baseline predictors for psychiatric hospitalization, and psychiatric diagnoses at follow-up were investigated and may give hints about possible preventative strategies. The medical records for 71 patients were reviewed 36 months following referral to OMT from a needle exchange program (NEP). Their psychiatric diagnoses and hospitalizations were identified. Their baseline characteristics were assessed for potential differences between hospitalized versus non-hospitalized patients and between patients with and without psychiatric diagnoses in a longitudinal observational study without controls. A regression analysis was performed to identify predictors for hospitalization when controlling for OMT status. Sixty-five percent of the patients were hospitalized at least once with a psychiatric diagnosis. Substance-related reasons were prevalent, and detoxification occurred among 59% of patients, with sedative- hypnotics (benzodiazepines, zopiclone, zolpidem, and pregabalin) being the substance used by 52% of patients. Baseline use of these drugs and/or buprenorphine predicted for hospitalization when controlling for OMT status. During the follow-up period, 72% of patients met the criteria for a psychiatric diagnosis other than OUD. The prevalence of non-substance use disorders overlapping with SUD was 41%, and that overlapping with anxiety disorder was 27% of all participants. Increased attention to psychiatric co-occurring disorders in the treatment of OUD is required and the importance of addressing sedative-hypnotics use when initiating OMT is highlighted.

Prevalence and correlates of non-fatal overdose among people who use drugs: findings from rapid assessments in Massachusetts, 2017-2019

BACKGROUND

People who experience non-fatal overdose (NFOD) are at high risk of subsequent overdose. With unprecedented increases in fentanyl in the US drug supply, many Massachusetts (MA) communities have seen a surge in opioid-related overdoses. The objective of this study was to determine factors associated with lifetime and past year NFOD in at-risk MA communities.

METHODS

We conducted multiple rapid assessments among people who use drugs (PWUD) in eight MA communities using non-probability sampling (purposive, chain referral, respondent-driven) methods. We collected sociodemographic, substance use, overdose history, substance use treatment, and harm reduction services utilization data. We examined the prevalence of NFOD (lifetime and past year) and identified factors associated with NFOD through multivariable logistic regression analyses in a subset of 469 study participants between 2017 and 2019.

RESULTS

The prevalence of lifetime and last year non-fatal opioid overdose was 62.5% and 36.9%, respectively. Many of the study participants reported heroin (64%) and fentanyl (45%) use during the 30 days preceding the survey. Nonprescription buprenorphine and fentanyl use were independently associated with higher odds of lifetime NFOD, while marijuana use was associated with lower odds of lifetime NFOD (p < 0.05). Injection as the route of administration, benzodiazepine, nonprescription buprenorphine, heroin, and fentanyl use were independently associated with higher odds, while methadone use was associated with lower odds of past year NFOD (p < 0.05).

CONCLUSION

We documented a high prevalence of past year and lifetime NFOD among PWUD in MA. Our findings provide indicators that can help inform interventions to prevent overdoses among PWUD, including overdose prevention, medication treatment, and naloxone distribution.

Investigating a bidirectional relationship between overdose and provision of injection initiation assistance among persons who inject drugs in Vancouver, Canada and Tijuana, Mexico

BACKGROUND

Individuals who initiate injection drug use often receive assistance from an injection-knowledgeable peer. Persons who assist peers in injection initiation events often inject frequently, which heightens overdose risk. As such, overdose and injection initiation events may be correlated. To explore a potential relationship, we assessed temporal associations between experiencing a non-fatal overdose and assisting others in initiating injection drug use among persons who inject drugs in two North American cities - Vancouver, Canada and Tijuana, Mexico.

METHODS

From 2014 to 2018, this retrospective cohort study included people who inject drugs from Vancouver (n=1332) and Tijuana (n=666) who completed a baseline and six-month follow-up interview. Within each site, we assessed bidirectional temporal associations using two separate multivariable logistic regression models: for model 1, recent provision of injection initiation assistance (at six months) was the outcome and recent overdose (at baseline) was the exposure; for model 2, recent overdose (at six months) was the outcome and recent provision of injection initiation assistance (at baseline) was the exposure. Both models adjusted for potential confounders.

RESULTS

Vancouver-based participants reporting overdose at baseline had 163% greater odds of reporting provision of injection initiation assistance at follow-up (adjusted Odds Ratio [aOR] 2.63; 95% Confidence Interval [CI] 1.41-4.90); while participants reporting provision of injection initiation assistance at baseline had 89% greater odds of reporting a non-fatal overdose at follow-up (aOR 1.89; 95% CI 1.00-3.57). Among Tijuana-based participants, we did not observe a statistically significant association in either direction.

CONCLUSION

Findings in Vancouver suggest that injection initiation assistance and overdose are bidirectionally-associated phenomena. The present findings highlight the need for interventions that ensure that persons who provide injection initiation assistance are given overdose prevention support, both for themselves and for those they assist to initiate injection drug use. While our Tijuana-based results did not suggest a bidirectional relationship, preventative approaches should nonetheless be undertaken.

Evaluation of drug-drug interactions in hospitalized patients on medications for OUD

Introduction

Medications used to treat OUD have common metabolic pathways and pharmacodynamic properties that can lead to drug-drug interactions (DDIs) that may go unnoticed in the inpatient setting. The purpose of this study was to identify the frequency of DDIs between medications prescribed for OUD and commonly used inpatient medications.

Methods

This was a retrospective review of orders for buprenorphine, buprenorphine-naloxone, and methadone to identify potential DDIs. Adult inpatients with an order for one of these medications for OUD were included. Medication regimens were evaluated throughout the inpatient stay and on day of discharge for DDIs. DDIs were classified by severity and type of interaction (increased risk of QT prolongation, additive CNS effects/respiratory depression, and opioid withdrawal). The primary endpoint was the number of potential DDIs. Other endpoints included number of each classification/severity of DDI, duration of therapy of interacting medications, and modifications made to OUD medications because of DDIs.

Results

A total of 102 patients were included, with 215 inpatient interactions and 83 interactions at discharge identified. While inpatient, 85% of patients were on an interacting medication, and 46% of patients were on an interacting medication at discharge. The most common classification of DDI was additive CNS effects/respiratory depression (68.8% inpatient, 50.6% discharge), followed by QT prolongation (24.2% inpatient, 45.8% discharge). The majority of DDIs were classified as requiring close monitoring rather than contraindicated.

Discussion

There are opportunities to optimize the prescribing practices surrounding OUD medications in both the inpatient setting and at discharge to ensure patient safety.

Changes in opioid-related deaths following increased access to opioid substitution treatment

BACKGROUND

Opioid-related mortality is high and increasing in the Western world, and interventions aimed at reducing opioid-related deaths represent an important area of study. In Skåne County, Sweden, a patient choice reform resulted in increased access to opioid substitution treatment (OST). In addition, a gradual shift towards less restrictive terms for exclusion from OST has been implemented. The aim of this study was to assess the impact of these policy changes on opioid-related deaths.

METHODS

Detailed data on opioid-related deaths in Skåne during the 2 years prior to and following the policy change were obtained from forensic records and from health care services. Data on overdose deaths for Skåne and the rest of Sweden were obtained using publicly available national register data. Time periods were used as the predictor for opioid-related deaths in the forensic data. The national level data were used in a natural experiment design in which rates of overdose deaths were compared between Skåne and the rest of Sweden before and after the intervention.

RESULTS

There was no significant difference in the number of deaths in Skåne between the data collection periods (RR: 1.18 95% CI:0.89-1.57, p= 0.251). The proportion of deaths among patients enrolled in OST increased between the two periods (2.61, 1.12-6.10, p= 0.026). There was no change in deaths related to methadone or buprenorphine in relation to deaths due to the other opioids included in the study (0.92, 0.51-1.63, p= 0.764). An analysis of national mortality data showed an annual relative decrease in unintentional drug deaths in Skåne compared to the rest of Sweden following the onset of the reform (0.90, 0.84-0,97, p= 0.004).

CONCLUSIONS

Opioid-related deaths, as assessed using forensic data, has not changed significantly in Skåne following a change to lower-threshold OST. By contrast, national level data indicate that the policy change has been associated with decreased overdose deaths. The discrepancy between these results highlights the need for more research to elucidate this issue. The result that more patients die during ongoing OST following an increase in access to treatment underlines the need for further preventive interventions within the OST treatment setting.

Evaluating the effectiveness of concurrent opioid agonist treatment and physician-based mental health services for patients with mental disorders in Ontario, Canada

Objective

The objective of this study was to evaluate the relationship between concurrent physician-based mental health services, all-cause mortality, and acute health service use for individuals enrolled in Opioid Agonist Treatment in Ontario, Canada.

Methods

A cohort study of patients enrolled in opioid agonist treatment in Ontario was conducted between January 1, 2011, and December 31, 2015, in Ontario with an inverse probability of treatment weights using the propensity score to estimate the effect of physician-based mental health services. Treatment groups were created based on opioid agonist treatment patients’ utilization of physician-based mental health services. Propensity score weighted odds ratios were calculated to assess the relationship between the treatment groups and the outcomes of interest. The outcomes included all-cause mortality using data from the Registered Persons Database, Emergency Department visits from the National Ambulatory Care Database, and hospitalizations using data from the Discharge Abstract Database. Encrypted patient identifiers were used to link across databases.

Results

A total of 48,679 individuals in OAT with mental disorders. Opioid agonist treatment alone was associated with reduced odds of all-cause mortality (odds ratio (OR) 0.4, 95% confidence interval (CI) 0.3–0.4). Patients who received mental health services from a psychiatrist and primary care physician while engaged in OAT, the estimated rate of ED visits per year was higher (OR = 1.3, 95% CI 1.2–1.4) and the rate of hospitalizations (OR = 0.5, 95% CI 0.4–0.6) than in the control group.

Conclusion

Our findings support the view that opioid agonist treatment and concurrent mental health services can improve clinical outcomes for complex patients, and is associated with enhanced use of acute care services.

Life expectancy of people who are dependent on opioids: A cohort study in New South Wales, Australia

BACKGROUND

People who are dependent on opioids have increased risk of premature death, but there are few estimates of life expectancy.

METHODS

We calculated age-specific mortality rates in a cohort of people who had at least one prescription of an opioid agonist (methadone or buprenorphine) between 2001 and 2018 in New South Wales, Australia. We used life tables to estimate life expectancy at age 18. We also estimated the potential years of life lost before age 75, decomposed by cause of death.

RESULTS

The cohort included 47,197 people, with a median of 9.8 years of follow-up. 5097 participants died, and the standardised mortality ratio (compared to the general population of New South Wales) was 6.06 (95% CI 5.90-6.23). Life expectancy at age 18 was an additional 47.5 years (95% CI 42.9-50.5) for men and 50.7 years (95% CI 45.4-54.8) for women; deficits of 14.7 and 15.8 years respectively when compared to the general population. The largest cause of death was non-communicable physical diseases, which accounted for 47% of deaths in life tables for men and 42% for women. Drug-related deaths accounted for 16% of deaths for men and 19% for women, but due to the young age at which these deaths occur, they contributed approximately one third of potential years of life lost.

CONCLUSION

In common with people with serious mental illnesses, people who are dependent on opioids have substantially reduced life expectancy. In both populations most excess deaths relate to non-communicable physical diseases.

"That's No Longer Tolerated": Policing Patients' Use of Non-opioid Substances in Methadone Maintenance Treatment

The current overdose crisis in the United States emphasizes the importance of providing substance use treatment programs that are not only effective but tailored to meet the specific needs of the populations they serve. While Methadone Maintenance Treatment (MMT) is considered to be among the best strategies for reducing rates of opioid-involved overdose, its ability to attract and maintain patients may be hindered by a recent focus on policing the non-opioid substance use of people on the program. This paper uses interview data from treatment providers to examine how clinicians conceptualize and organize MMT in regards to patients' use of non-opioid drugs. Responses demonstrate that some treatment providers are increasingly monitoring their patients' use of non-opioid substances and punishing them for infractions, up to and including discharge from treatment. This approach will likely result in increasing rates of patient dropout and a lack of new admissions among people who use non-opioid substances. This article argues that including non-opioid substances in MMT's mandate restricts its ability to improve public health, including by preventing overdoses, and recommends instead that MMT adopt a more individualized approach, shaped by the needs and goals of the patient rather than those of the clinician.

Baseline Factors Associated with Mortality in Patients Who Engaged in Buprenorphine Treatment for Opioid Use Disorder: a Cohort Study

BACKGROUND

Opioid agonist therapy (OAT) has been shown to reduce mortality in patients with opioid use disorder (OUD), yet mortality in individuals receiving OAT remains higher than in an age- and gender-matched population.

OBJECTIVE

To identify baseline risk factors in patients who engaged in buprenorphine treatment that are associated with this elevated risk of death.

DESIGN

We performed a retrospective cohort study from January 1, 2007, to December 31, 2018, using a centralized clinical data registry within a multi-hospital health system in Boston, MA, USA.

PARTICIPANTS

All adult patients who had ≥ 2 consecutive encounters with sublingual buprenorphine on the active medication list from January 1, 2007, to December 31, 2018.

MAIN MEASURES

We abstracted several sociodemographic, clinical, and healthcare use characteristics from the clinical data registry. The primary outcome was all-cause mortality and the secondary outcome was opioid overdose-related mortality. We performed multivariable cox regression to identify baseline characteristics independently associated with these outcomes.

KEY RESULTS

Of 5948 patients in the cohort, the majority were white (80.7%) and male (59.7%), with a mean age of 38.2 years. The all-cause mortality rate was 24.0 deaths per 1000 person-years. Baseline characteristics independently associated with an increased hazard of all-cause mortality included homelessness (adjusted hazard ratio [aHR] = 1.39; 95% confidence interval [CI] = 1.09, 1.78), an opioid on the active medication list (aHR = 1.28; 95% CI = 1.08, 1.52), and entry into the cohort during an inpatient hospitalization (aHR = 1.43; 95% CI = 1.18, 1.73). Homelessness was also associated with an increased hazard of opioid overdose-related mortality (aHR = 1.77; 95% CI = 1.25, 2.50).

CONCLUSIONS

We identified several novel and potentially modifiable predictors of mortality among patients engaging in buprenorphine treatment who remain at an increased risk of death compared with the general population. Understanding these risk factors can assist healthcare providers in risk stratification and inform the design of targeted interventions to improve outcomes in a high-risk patient population.

Impact of Pharmacological Treatments for Opioid Use Disorder on Mortality

The use of pharmacological treatments for opioid use disorders, including methadone, buprenorphine and naltrexone has been associated with a reduction in mortality compared with illicit opioid use. However, these treatments can also contribute significantly to the risk of death. The opioid agonists methadone and buprenorphine achieve clinical efficacy in patients with an opioid use disorder through suppressing craving and diminishing the effectiveness of illicit opioid doses, while the antagonist naltrexone blocks the action of opioids. Pharmacological differences between opioid pharmacotherapies then create different temporal patterns of protection and mortality risk, different risks of relapse to illicit opioid use, and variations in direct and indirect toxicity, which are revealed in clinical and epidemiological studies. Induction onto methadone and the cessation of oral naltrexone treatment are associated with an elevated risk of opioid poisoning, which is not apparent in patients treated with buprenorphine or sustained-release naltrexone. Beyond drug-related mortality, these pharmacotherapies can impact a participant's risk of death. Buprenorphine may also have some advantages over methadone in patients with depressive disorders or cardiovascular abnormalities. Naltrexone, which is also commonly prescribed to manage problem alcohol use, may reduce deaths in chronic co-alcohol users. Understanding these pharmacologically driven patterns then guides the judicious choice of drug and dosing schedule and the proactive risk management that is crucial to minimising the risk of death in treatment.

Effects of medication-assisted treatment on mortality among opioids users: a systematic review and meta-analysis

Opioid use disorder (OUD) is associated with a high risk of premature death. Medication-assisted treatment (MAT) is the primary treatment for opioid dependence. We comprehensively assessed the effects of different MAT-related characteristics on mortality among those with OUD by a systematic review and meta-analysis. The all-cause and overdose crude mortality rates (CMRs) and relative risks (RRs) by treatment status, different type, period, and dose of medication, and retention time were pooled using random effects, subgroup analysis, and meta-regression. Thirty cohort studies involving 370,611 participants (1,378,815 person-years) were eligible in the meta-analysis. From 21 studies, the pooled all-cause CMRs were 0.92 per 100 person-years (95% CI: 0.79-1.04) while receiving MAT, 1.69 (1.47-1.91) after cessation, and 4.89 (3.54-6.23) for untreated period. Based on 16 studies, the pooled overdose CMRs were 0.24 (0.20-0.28) while receiving MAT, 0.68 (0.55-0.80) after cessation of MAT, and 2.43 (1.72-3.15) for untreated period. Compared with patients receiving MAT, untreated participants had higher risk of all-cause mortality (RR 2.56 [95% CI: 1.72-3.80]) and overdose mortality (8.10 [4.48-14.66]), and discharged participants had higher risk of all-cause death (2.33 [2.02-2.67]) and overdose death (3.09 [2.37-4.01]). The all-cause CMRs during and after opioid substitution treatment with methadone or buprenorphine were 0.93 (0.76-1.10) and 1.79 (1.47-2.10), and corresponding estimate for antagonist naltrexone treatment were 0.26 (0-0.59) and 1.97 (0-5.18), respectively. Retention in MAT of over 1-year was associated with a lower mortality rate than that with retention ≤1 year (1.62, 1.31-1.93 vs. 5.31, -0.09-10.71). Improved coverage and adherence to MAT and post-treatment follow-up are crucial to reduce the mortality. Long-acting naltrexone showed positive advantage on prevention of premature death among persons with OUD.

Opioid agonist treatment scale-up and the initiation of injection drug use: A dynamic modeling analysis

BACKGROUND

Injection drug use (IDU) is associated with multiple health harms. The vast majority of IDU initiation events (in which injection-naïve persons first adopt IDU) are assisted by a person who injects drugs (PWID), and as such, IDU could be considered as a dynamic behavioral transmission process. Data suggest that opioid agonist treatment (OAT) enrollment is associated with a reduced likelihood of assisting with IDU initiation. We assessed the association between recent OAT enrollment and assisting IDU initiation across several North American settings and used dynamic modeling to project the potential population-level impact of OAT scale-up within the PWID population on IDU initiation.

METHODS AND FINDINGS

We employed data from a prospective multicohort study of PWID in 3 settings (Vancouver, Canada [n = 1,737]; San Diego, United States [n = 346]; and Tijuana, Mexico [n = 532]) from 2014 to 2017. Site-specific modified Poisson regression models were constructed to assess the association between recent (past 6 month) OAT enrollment and history of ever having assisted an IDU initiation with recently assisting IDU initiation. Findings were then pooled using linear mixed-effects techniques. A dynamic transmission model of IDU among the general population was developed, stratified by known factors associated with assisting IDU initiation and relevant drug use behaviors. The model was parameterized to a generic North American setting (approximately 1% PWID) and used to estimate the impact of increasing OAT coverage among PWID from baseline (approximately 21%) to 40%, 50%, and 60% on annual IDU initiation incidence and corresponding PWID population size across a decade. From Vancouver, San Diego, and Tijuana, respectively, 4.5%, 5.2%, and 4.3% of participants reported recently assisting an IDU initiation, and 49.4%, 19.7%, and 2.1% reported recent enrollment in OAT. Recent OAT enrollment was significantly associated with a 45% lower likelihood of providing recent IDU initiation assistance among PWID (relative risk [RR] 0.55 [95% CI 0.36-0.84], p = 0.006) compared to those not recently on OAT. Our dynamic model predicts a baseline mean of 1,067 (2.5%-97.5% interval [95% I 490-2,082]) annual IDU initiations per 1,000,000 individuals, of which 886 (95% I 406-1,750) are assisted by PWID. Based on our observed statistical associations, our dynamic model predicts that increasing OAT coverage from approximately 21% to 40%, 50%, or 60% among PWID could reduce annual IDU initiations by 11.5% (95% I 2.4-21.7), 17.3% (95% I 5.6-29.4), and 22.8% (95% I 8.1-36.8) and reduce the PWID population size by 5.4% (95% I 0.1-12.0), 8.2% (95% I 2.2-16.9), and 10.9% (95% I 3.2-21.8) relative to baseline, respectively, in a decade. Less impact occurs when the protective effect of OAT is diminished, when a greater proportion of IDU initiations are unassisted by PWID, and when average IDU career length is longer. The study's main limitations are uncertainty in the causal pathway between OAT enrollment and assisting with IDU initiation and the use of a simplified model of IDU initiation.

CONCLUSIONS

In addition to its known benefits on preventing HIV, hepatitis C virus (HCV), and overdose among PWID, our modeling suggests that OAT scale-up may also reduce the number of IDU initiations and PWID population size.

Reduction in mortality risk with opioid agonist therapy: a systematic review and meta-analysis

INTRODUCTION

Opioid agonist therapies are effective medications that can greatly improve the quality of life of individuals with opioid use disorder. However, there is significant uncertainty about the risks of cause-specific mortality in and out of treatment.

OBJECTIVE

This systematic review and meta-analysis explored the association between methadone and buprenorphine with cause-specific mortality among opioid-dependent persons.

METHODS

We searched six online databases to identify relevant cohort studies, calculating all-cause and overdose-specific mortality rates during periods in and out of treatment. We pooled mortality estimates using multivariate random effects meta-analysis of the crude mortality rate per 1000 person-years of follow-up as well as relative risks comparing mortality in vs. out of treatment.

RESULTS

A total of 32 cohort studies (representing 150 235 participants, 805 423.6 person-years, and 9112 deaths) met eligibility criteria. Crude mortality rates were substantially higher among methadone cohorts than buprenorphine cohorts. Relative risk reduction was substantially higher with methadone relative to buprenorphine when time in-treatment was compared to time out-of-treatment. Furthermore, the greatest mortality reduction was conferred during the first 4 weeks of treatment. Mortality estimates were substantially heterogeneous and varied significantly by country, region, and by the nature of the treatment provider.

CONCLUSION

Precautions are necessary for the safer implementation of opioid agonist therapy, including baseline assessments of opioid tolerance, ongoing monitoring during the induction period, education of patients about the risk of overdose, and coordination within healthcare services.

Self-Rated Physical Health and Unmet Healthcare Needs among Swedish Patients in Opioid Substitution Treatment

Background

Individuals with opioid dependence are at increased risk of deteriorating health due to the lifestyle connected to heroin use. Barriers surrounding the healthcare system seem to hinder patients to seek help through conventional healthcare, even after entering opioid substitution treatment (OST), resulting in a high level of unmet healthcare needs. However, this field is still unexplored, with only a few studies focusing on general health within this population. The first step, in order to provide suitable and accessible primary healthcare, is to assess the extent of physical symptoms and unmet healthcare needs within the OST population, which, to this point, has been sparsely studied.

Aim

To assess OST patients' self-rated physical health and healthcare seeking behaviour.

Methods

Two-hundred and eighteen patients from four different OST sites answered a questionnaire regarding physical health and healthcare seeking.

Results

Patients in OST have a high degree of physical symptoms and a high degree of unmet healthcare needs. Sixty-six percent reported suffering from musculoskeletal pain. Fifty-six percent reported gastrointestinal symptoms. Genital problems and airway symptoms were reported by 47%, respectively, and dental problems were reported by 69% of the respondents. General unmet healthcare needs were reported by 82%. Musculoskeletal pain was positively correlated with having an unstable housing situation (AOR 4.26 [95% CI 1.73-10.48]), negatively correlated with male sex (AOR 0.45 [95% CI 0.22-0.91]), and positively correlated with age (AOR 1.04 [95% CI 1.01-1.07]). No statistically significant correlates of respiratory, gastrointestinal, genital, or dental symptoms were found.

Conclusion

Patients in OST carry a heavy burden of physical symptoms and unmet healthcare needs, potentially due to societal barriers. Patients' frequent visits to the OST clinics offer a unique opportunity to build a base for easily accessible on-site primary healthcare.

Non-Medical Use of Novel Synthetic Opioids: A New Challenge to Public Health

Background: In the last decade there has been a progressive increase in the use of new psychoactive substances (NPSs) that are not yet under international control. In particular, novel synthetic opioids (NSOs) have reappeared on the recreational drug market in the last few years. As a result, the use of NSOs has increased rapidly. This poses an emerging and demanding challenge to public health. Aim: To raise awareness among clinicians and other professionals about NPSs, especially NSOs, to summarize current knowledge about pharmacological properties, forms of NSO on the market, pattern of use, effects and consequences of use. Methods: An electronic search was carried out on the Medline/PubMed and Google Scholar databases to find selected search terms. Results: Some NPSs are already controlled, while others can be legally sold directly on the drug market (mainly via internet, less so by drug dealers) or be used as precursors for the synthesis of other designer drugs that mimic the psychoactive effects of controlled substances. Potential side-effects of NSOs include miosis, sedation, respiratory depression, hypothermia, inhibition of gastrointestinal propulsion, death (from opioid overdose). Conclusions: The severity of the opioid crisis has intensified with the introduction of highly potent NSOs on the drug market. As long as addicts are dying from overdose or similar causes, there is something more constructive to do than waiting for addicts to overdose on heroin at a place located near a remedy, as if to say, within reach of naloxone.

A comparison of sexual desire in opiate-dependent men receiving methadone and buprenorphine maintenance treatment

BACKGROUND

Methadone is an effective therapy for opiate dependence. However, one of the commonest side effects is sexual dysfunction among male patients. Buprenorphine is an alternative to methadone. This study aimed to compare sexual desire among opiate-dependent male patients on buprenorphine (BMT) and methadone maintenance therapy (MMT).

METHODS

This cross-sectional study involved 126 male opiate-dependent patient who were tested for total testosterone (TT) and prolactin levels, and were interviewed and completed the Sexual Desire Inventory-2 (SDI-2), Malay language of International Index of Erectile Function (Mal-IIEF-15) and the Malay version of the self-rated Montgomery-Asberg Depression Rating Scale (MADRS-BM) questionnaires.

RESULTS

There were 95 (75.4%) patients on MMT and 31 (24.6%) on BMT. Patients on MMT scored significantly lower in the sexual desire domain (Mal-IIEF-15 scores) (p < 0.01), dyadic sexual desire (p = 0.04) and TT plasma level (p < 0.01) when compared to BMT group after controlling all the confounders.

CONCLUSIONS

Patients on MMT are associated with lower sexual desire when compared with patients on BMT. Smoking may further lower testosterone and, hence, sexual desire in those already on methadone.

Health Related Quality of Life in Individuals Transferred from a Needle Exchange Program and Starting Opioid Agonist Treatment

Background

Opioid agonist treatment (OAT), for the treatment of heroin dependence, has been reported to improve overall health and lower mortality. Drug use and retention in treatment have often been used as measures of treatment success. More recently, however, researchers have suggested that measurements of quality of life should be an outcome in substance use treatment evaluations. In a recent randomized controlled trial we demonstrated high rates of successful rapid referral from a needle exchange program (NEP) to OAT. The aim of this study was to see whether an improvement in health related quality of life (HRQoL) could be seen at 3-month follow-up after starting OAT and whether it was associated with any baseline characteristics. We also wanted to compare our sample to a sample from the general population with regard to HRQoL.

Methods

This was a 3-month follow-up of 71 patients who started OAT. Measurements of HRQoL with EQ-5D (an instrument developed by the EuroQol group) were made at baseline and at three months.

Results

Mean EQ-5D VAS (visual analogue scale) for the study sample at baseline was 47.3, which was lower than a Swedish reference population reporting 83.3. Individuals reporting being prescribed a drug for a psychiatric condition had significantly lower EQ-5D index values. Improvement in EQ-5D index score was significantly less for individuals reporting previous overdoses (-0.10, p=0.025). Individuals reporting previous suicide attempts had significantly lower EQ-5D VAS score at baseline. A significant increase of the EQ-5D VAS difference over time was found with a mean difference of 10.94 (p=0.008) for the total sample.

Conclusion

To our knowledge this is the first time HRQoL as an outcome is reported in a population transferred from a NEP to OAT. Our results indicate that OAT can result in increased HRQoL, even with this type of rapid low-threshold referral.

21st Century Cures for the Opioid Crisis: Promise, Impact, and Missed Opportunities

Signed into law in 2016, the landmark 21stCentury Cures Act is as complex as it is divisive. For some stakeholders, including patient groups and representatives of regulated industries, the Act represented a major leap forward in pharmaceutical innovation, human subjects protections, and numerous other provisions. For other observers, this legislation was characterized as a major rollback in important regulations, which would leave patients worse off and the payers holding the bag. The one element of the Act that was relatively uncontroversial covered a number of provisions related to addressing the opioid crisis.

This was by design. Provisions related to this issue were not part of the original legislation and were added to win over additional members of Congress who needed to be brought along to support the legislation. Many of the statute's provisions were intertwined with the Comprehensive Addiction Recovery Act (“CARA”) passed previously, but that legislation was stripped of much of its funding for opioid crisis response.

Similarities and changes between 15- and 24-year survival and retention rates of patients in a large medical-affiliated methadone maintenance treatment (MMT) center

BACKGROUND

Environmental and social trends and patients' characteristics may affect predictors for methadone maintenance treatment (MMT) outcome.

METHODS

We have expanded our previous study of predictors for MMT outcome (from 619 to 890 patients) and the study period (from 15 to 24 years). Survival and retention in MMT since admission to the MMT clinic (6/1993-6/2016) and until death or study closure (6/2017) were compiled and analyzed.

RESULTS

Of 890 patients ever admitted (10,146.9 person-years (py)), 237 passed away (116 while in MMT). The mortality rate did not differ between those who stayed or left (2.6 vs. 2.1 per 100 py, p = 0.1), but it was lower among those who stayed ≥1 year during any admission (2.1 vs. 3.3 per 100 py, respectively, p = 0.004). Age <40 years, no hepatitis C or B, no HIV, and no benzodiazepine abuse after one year predicted longer survival (multivariate analyses). No opiate or benzodiazepine abuse after one year, methadone dose ≥100 mg/d, no DSM-IV-TR Axis II diagnosis only, and no direct hospital referral predicted longer retention. Cocaine abuse predicted poor retention and survival among 271 patients admitted during the extended part of the study period.

CONCLUSIONS

Predictors for retention (associated with MMT outcome) and mortality (associated with pre-treatment comorbidity) after 24 years were similar to those after 15 years. Cocaine abuse as a predictor of both poor retention and poor survival in the later period may reflect the escalating trend for cocaine abuse and should be studied if related to other unmonitored substances.

[Harm reduction interventions in drug users: current situation and recommendations]

Harm reduction encompasses interventions, programmes and policies that seek to reduce the negative consequences of the consumption of both legal and illegal drugs on the individual and public health. Harm reduction looks to mitigate the harm suffered by drug users through drug use monitoring and prevention, and promotes initiatives that respect and protect the human rights of this population. The harm reduction policies that have proven effective and efficient are: opioid substitution maintenance therapy (methadone); needle and syringe exchange programmes; supervised drug consumption rooms; and overdose prevention through peer-based naloxone distribution. In order to be effective, these policies must have comprehensive coverage and be implemented in areas where the target population is prevalent. Resident-based opposition to the implementation of these policies is known as the NIMBY (Not In My Back Yard) phenomenon, which is characterised by being against the implementation of new measures in a particular place, but does not question their usefulness. Given that any NIMBY phenomenon is a complex social, cultural and political phenomenon, it is important to conduct a thorough analysis of the situation prior to implementing any of these measures. Harm reduction policies must be extended to other substances such as alcohol and tobacco, as well as to other conditions beyond infectious/contagious diseases and overdose.

Increasing availability of benzodiazepines among people who inject drugs in a Canadian setting

BACKGROUND

Benzodiazepine misuse is associated with mortality and is common among people who inject drugs (PWID). This study aimed to examine the temporal trends in the availability of benzodiazepines among PWID in a Canadian setting, and to identify factors associated with more immediate access to benzodiazepines.

METHODS

Data were derived from 3 prospective cohorts of PWID in Vancouver, Canada, between June 2012 and May 2015. The primary outcome was the perceived availability of benzodiazepines, measured in 3 levels: not available, delayed availability (available in ≥10 minutes), and immediate availability (available in <10 minutes). The authors used multivariable generalized estimating equations to identify factors associated with availability of benzodiazepines.

RESULTS

In total, 1641 individuals were included in these analyses. In multivariable analyses, factors associated with immediate benzodiazepine availability included incarceration (adjusted odds ratio [AOR]: 1.42, 95% confidence interval [CI]: 1.06, 1.89) and participation in methadone maintenance therapy (MMT) (AOR: 1.35, 95% CI: 1.14, 1.60). Factors associated with delayed benzodiazepine availability included incarceration (AOR: 1.45, 95% CI: 1.02, 2.07) and participation in MMT (AOR: 1.77, 95% CI: 1.48, 2.12). Benzodiazepine availability increased throughout the study period for both immediate (AOR: 1.14, 95% CI: 1.10, 1.18 per 6-month follow-up period) and delayed (AOR: 1.17, 95% CI: 1.12, 1.22 per 6-month follow-up period) availability.

CONCLUSIONS

Among our sample of PWID, benzodiazepine availability is increasing and was associated with health and criminal justice system characteristics. Our findings indicate a need to examine prescribing practices and educate both PWID and health care providers about the risks associated with benzodiazepine use.

Effect of ageing and time since first heroin and cocaine use on mortality from external and natural causes in a Spanish cohort of drug users

BACKGROUND

We aimed to assess the effect of ageing and time since first heroin/cocaine use on cause-specific mortality risk and age disparities in excess mortality among heroin (HUs) and cocaine users (CUs) in Spain.

METHODS

A cohort of 15,305 HUs and 11,905 CUs aged 15-49 starting drug treatment during 1997-2007 in Madrid and Barcelona was followed until December 2008. Effects of ageing and time since first heroin/cocaine use were estimated using a competing risk Cox model and the relative and absolute excess mortality compared to the general population through directly age-sex standardized rate ratios (SRRs) and differences (SRDs), respectively.

RESULTS

Mortality risk from natural causes increased with time since first heroin use, whereas that from overdose declined after having peaked in the first quinquennium. Significant effects of time since first cocaine use were not identified, although fatal overdose risk seemed higher in CUs after five years. Mortality risk from natural causes (HUs and CUs), injuries (HUs), and overdoses (CUs) increased with age, the latter without reaching statistical significance. Crude mortality rates from overdoses and injuries remained very high at age 40-59 among both HUs (595 and 217 deaths/100,000 person-years, respectively) and CUs (191 and 88 deaths/100,000 person-years). SRDs from all and natural causes were much higher at age 40-59 than 15-29 in both HUs (2134 vs. 834 deaths/100,000 person-years) and CUs (927 vs. 221 deaths/100,000 person-years), while the opposite occurred with SRRs.

CONCLUSION

The high mortality risk among HUs and CUs at all ages from both external and natural causes, and increased SRDs with ageing, suggest that high-level healthcare and harm reduction services should be established early and maintained throughout the lifetime of these populations.

A cross-national analysis of the association between years of implementation of opioid substitution treatments and drug-related deaths in Europe from 1995 to 2013

Data at the individual-level provide evidence that opioid substitution treatment (OST) programs protect against mortality for opioid dependent populations. Prior research has not examined the merits of national implementation of opioid substitution programs for reducing mortality at the country-level. This study elucidates longitudinal associations between country-level implementation of opioid substitution treatment programs on mortality rates of drug related deaths (DRD) from 1995 to 2013 in 30 European nations. Cases of DRD were measured using National Definitions for each country from official sources of data. Preliminary analysis of dispersion of cases of DRD using means and variances justified use of the negative binomial regression model with a population offset. Year and country-level fixed effects negative binomial regression models investigated the association between years of implementation of methadone maintenance therapy (MMT), OST in prison, and high dose buprenorphine treatment (HDBT) implementation and mortality rates from drug related deaths after adjusting for unemployment rates, heroin seizures and per capita expenditures on health. Beta coefficients were converted to Incidence Rate Ratios (IRR) and standard errors bootstrapped using non-parametric methods to adjust for bias (SD_bs). The mean mortality rate of DRD was 1.81 from 1995 to 2013. In adjusted models, each additional year of MMT (IRR = .61, SD = .04, p < .001; SD_bs = .08, p < .001), prison OST (IRR = .90, SD = .01, p < .001; SD_bs = .02, p < .001), and HDBT (IRR = .09, SD = .02, p < .001; SD_bs = .02, p < .01) was significantly associated with lower rates of DRDs after adjusting for country and year fixed effects. Implementation of OST programs in the general population and in prison settings may have protected against mortality from drug use at the country-level in Europe from 1995 to 2013.

Characteristics of adherence to methadone maintenance treatment over a 15-year period among homeless adults experiencing mental illness

BACKGROUND

Methadone maintenance treatment (MMT) has important protective effects related to reduced illicit opioid use, infectious disease transmission, and overdose mortality. Adherence to MMT has not been examined among homeless people. We measured MMT adherence and reported relevant characteristics among homeless adults experiencing mental illness in Vancouver, British Columbia, Canada.

MATERIAL AND METHODS

Homeless adults living with mental illness who had received MMT prior to the baseline interview of the Vancouver At Home study (n = 78) were included in analyses. The medication possession ratio (MPR) was used to estimate MMT adherence from retrospective administrative pharmacy and public health insurance data collected across 15 years. Independent sample t tests and one-way ANOVA were used to test for significant differences in MMT MPR by participant characteristics.

RESULTS

Mean MMT MPR was 0.47. A large proportion of participants reported blood-borne infectious disease, three or more chronic physical health conditions, and substance use. Being single and never married was associated with significantly lower MMT MPR (0.40 vs. 0.55, p = 0.036), while living with schizophrenia, bipolar disorder, or a mood disorder with psychotic features was associated with significantly higher MMT MPR (0.54 vs. 0.37, p = 0.022). Daily drug use (excluding alcohol) was associated with significantly lower MMT MPR (0.39 vs. 0.54, p = 0.051).

CONCLUSIONS

The level of adherence to MMT was very low among homeless adults experiencing mental illness. Efforts are needed to improve adherence to MMT as a means of reducing illicit substance use, preventing overdose deaths, and attenuating infectious disease transmission.

The opioid crisis: past, present and future policy climate in Ontario, Canada

BACKGROUND

Addressing opioid use disorder has become a priority in Ontario, Canada, because of its high economic, social and health burden. There continues to be stigma and criticism relating to opioid use disorder and treatment options. The result has been unsystematic, partial, reactive policies and programs developed based on divergent points of view. The aim of this manuscript is to describe how past and present understandings, narratives, ideologies and discourse of opioid use, have impacted policies over the course of the growing opioid crisis.

COMMENTARY

Assessing the impact of policy is complex. It involves consideration of conceptual issues of what impacts policy change. In this manuscript we argue that the development of polices and initiatives regarding opioids, opioid use disorder and opioid agonist treatment in the last decade, have been more strongly associated with the evolution of ideas, narratives and discourses rather than research relating to opioids. We formulate our argument using a framework by Sumner, Crichton, Theobald, Zulu, and Parkhurs. We use examples from the Canadian context to outline our argument such as: the anti- drug legislation from the Canadian Federal Conservative government in 2007; the removal of OxyContin™ from the drug formulary in 2012; the rapid expansion of opioid agonist treatment beginning in the early 2000s, the unilateral decision made regarding fee cuts for physicians providing opioid agonist treatment in 2015; and the most recent implementation of a narcotics monitoring system, which are all closely linked with the shifts in public opinion and discourse at the time of which these policies and programs are implemented.

CONCLUSION

We conclude with recommendations to consider a multifactorial response using evidence and stakeholder engagement to address the opioid crisis, rather than a reactive policy approach. We suggest that researchers have an important role in shaping future policy by reframing ideas through knowledge translation, formation of values, creation of new knowledge and adding to the quality of public discourse and debate.

Large variation in measures used to assess outcomes of opioid dependence treatment: A systematic review of longitudinal observational studies

ISSUES

Treatment outcomes for drug users are critical for informing policy and therapeutic practice. The coherence of outcomes, changes and drug use measures from observational studies on opioid use treatment were reviewed.

APPROACH

Systematic review of the literature for longitudinal observational studies, from 1980 through November 2015, in all languages, with data on treated opioid users, using Pubmed, the Cochrane Library and additional strategies (e.g. Pubmed function 'related citations' and checking reference lists of eligible studies).

KEY FINDINGS

Twenty-seven studies were included (11 countries, 85 publications, recruitment 1962-2009). Baseline n was >65 686 and median follow-up 34.5 months (21 studies) or 51.4 person-months (10 studies). Eight outcome domains were identified: 'drug use' (21/27 studies), 'crime' (13), 'health' (13), 'treatment-related' outcomes (16), 'social functioning' (13), 'harms' (8), 'mortality' (13) and 'economic estimates' (2 studies). All studies using drug use outcomes included a binary (abstinence) category in at least one measure. Studies typically reported outcomes on less than half (on average 3.7 or 46%) of the eight outcome domains, while the average was 5.1 (64%) in seven studies initiated since 2000.

IMPLICATIONS AND CONCLUSION

Wide variation exists in outcome measures found in longitudinal observational studies of treatment of opioid users. This reduces replicability of studies and suggests a lack of common expectations on treatment success. Future studies should consider using all or most of eight outcome domains identified (excluding economic analyses if unfeasible), non-binary measures and amount/value of drugs used and consensus meetings with joint ownership of scientific, treatment and patient communities.

Young people who use drugs engaged in harm reduction programs in New York City: Overdose and other risks

BACKGROUND

Little is known about the engagement of young people who use drugs (PWUD) in harm reduction programs (HRPs), and few studies have included non-opioid users and non-injectors. While HRPs have effectively engaged PWUD, young people are under-represented in their services.

METHODS

The Injection Drug Users Health Alliance Citywide Study (IDUCS) is the largest community-based study of PWUD in HRPs in the US. From 2014-2015, 2421 HRP participants across New York City (NYC) completed a cross-sectional survey. We investigated differences in socio-demographics, service utilization, and risk behaviors between young (aged 18-30) and older participants and examined factors associated with overdose among young participants.

RESULTS

The study included 257 young participants. They were significantly more likely than older participants to be white, educated, uninsured, unstably housed or homeless, and have a history of incarceration and residential drug treatment. They were more likely to report recent overdose but less likely to report knowledge of naloxone. Young participants also had higher rates of alcohol, marijuana, benzodiazepine, and injection drug use, and related risk behaviors such as public injection. Factors associated with past year overdose among young participants included experiencing symptoms of psychological distress (AOR=9.71), being unstably housed or homeless (AOR=4.39), and utilizing detox (AOR=4.20).

CONCLUSIONS

Young PWUD who access services at HRPs in NYC differ significantly from their older counterparts. New York City and other urban centers that attract young PWUD should consider implementing harm reduction oriented services tailored to the unique needs of young people.

Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies

Objective To compare the risk for all cause and overdose mortality in people with opioid dependence during and after substitution treatment with methadone or buprenorphine and to characterise trends in risk of mortality after initiation and cessation of treatment.Design Systematic review and meta-analysis.Data sources Medline, Embase, PsycINFO, and LILACS to September 2016.Study selection Prospective or retrospective cohort studies in people with opioid dependence that reported deaths from all causes or overdose during follow-up periods in and out of opioid substitution treatment with methadone or buprenorphine.Data extraction and synthesis Two independent reviewers performed data extraction and assessed study quality. Mortality rates in and out of treatment were jointly combined across methadone or buprenorphine cohorts by using multivariate random effects meta-analysis.Results There were 19 eligible cohorts, following 122 885 people treated with methadone over 1.3-13.9 years and 15 831 people treated with buprenorphine over 1.1-4.5 years. Pooled all cause mortality rates were 11.3 and 36.1 per 1000 person years in and out of methadone treatment (unadjusted out-to-in rate ratio 3.20, 95% confidence interval 2.65 to 3.86) and reduced to 4.3 and 9.5 in and out of buprenorphine treatment (2.20, 1.34 to 3.61). In pooled trend analysis, all cause mortality dropped sharply over the first four weeks of methadone treatment and decreased gradually two weeks after leaving treatment. All cause mortality remained stable during induction and remaining time on buprenorphine treatment. Overdose mortality evolved similarly, with pooled overdose mortality rates of 2.6 and 12.7 per 1000 person years in and out of methadone treatment (unadjusted out-to-in rate ratio 4.80, 2.90 to 7.96) and 1.4 and 4.6 in and out of buprenorphine treatment.Conclusions Retention in methadone and buprenorphine treatment is associated with substantial reductions in the risk for all cause and overdose mortality in people dependent on opioids. The induction phase onto methadone treatment and the time immediately after leaving treatment with both drugs are periods of particularly increased mortality risk, which should be dealt with by both public health and clinical strategies to mitigate such risk. These findings are potentially important, but further research must be conducted to properly account for potential confounding and selection bias in comparisons of mortality risk between opioid substitution treatments, as well as throughout periods in and out of each treatment.

Managing Opioid Abuse in Older Adults: Clinical Considerations and Challenges

Opioid use disorder is a public health epidemic. There is increasing attention being given to opioid abuse and overdose in the United States. The overall use of illicit substances by older adults is on the rise and in part can be attributed to the aging of Baby Boomers. Furthermore, much attention is being given to prescription opioid drug overdose, but it is important to note that heroin-related deaths have also increased sharply. Heroin use is part of a larger substance abuse problem, with more than nine in 10 individuals who use heroin also using at least one other drug (e.g., cocaine, prescription opioid medication). The current article highlights treatment approaches, namely buprenorphine, buprenorphine/naloxone, and naltrexone; insurance considerations; and resources to aid in understanding and managing this public health crisis.

Mortality trends among heroin users treated between 1975 and 2013 in Northern Italy: Results of a longitudinal study

BACKGROUND

The aim of this study was to examine heroin mortality trends and changes in causes of death, across time and age, in a cohort of the heroin population of treated.

METHODS

5899 subjects attending twelve centers for addiction treatment (SERT) in north Italy following problems due to heroin abuse between 1975 and 2013 were recruited.

RESULTS

This study documented elevated mortality among subjects with primary heroin abuse, with an elevated death risk in all the classes of age, declining until 2009 ad increasing starting from 2010. AIDS was the first cause of death, followed by overdose and liver-related diseases. In the course of time mortality for AIDS and for drug-related deaths has declined, whereas liver mortality and all tumors mortality have risen over time, becoming the most common causes of death by the end of the follow up. As compared with the general population, the excess mortality (SMR) observed for all causes in either sex was 13.2, higher in females (SMR=21.5) as compared with males (SMR=12.1). Higher SMRs were found in 25/34 age-group patients, with a progressive decrease in subjects with age >34years.

CONCLUSIONS

In the course of time, among heroin users, mortality and the causes of death have changed; for SERT clients special attention should be paid to the prevention and treatment of liver-related diseases.

Malmö Treatment Referral and Intervention Study-High 12-Month Retention Rates in Patients Referred from Syringe Exchange to Methadone or Buprenorphine/Naloxone Treatment

BACKGROUND

Heroin dependence is associated with high mortality. Opioid agonist treatment (OAT) with methadone or buprenorphine has strong evidence for treatment of this relapsing condition. In our setting, OAT has been associated with strict and demanding intake procedures, often with requirements of social stability, but also high, approximately 80 percent 12-month retention rates. In a recent randomized controlled trial, we demonstrated high rates of successful rapid referral from a syringe exchange programme (SEP) to treatment with methadone or buprenorphine, including actual treatment initiation. The objectives of this study were to assess 12-month retention rates, in order to assess whether a novel referral program of current drug users at a SEP would achieve retention rates comparable to more traditional intake procedures.

METHODS

The present report is a 12-month follow-up of 71 patients who successfully started treatment with methadone or buprenorphine/naloxone. Patient data from baseline and at 12 months were collected.

RESULTS

Out of the 71 patients who started treatment, 58 (82%) were still in treatment after 12 months.

CONCLUSION

This was a population, referred from a SEP, with a high drug use severity on admission and no pretreatment requirement for social stability, but there were still high retention rates at 12 months comparable to regular opioid agonist clinics in our setting.

Fatal and non-fatal overdose after narcology hospital discharge among Russians living with HIV/AIDS who inject drugs

OBJECTIVES

Among Russians living with HIV/AIDS who inject drugs, we examined the incidence of fatal and non-fatal overdoses following discharge from a narcology hospital and the associations with more advanced HIV infection.

DESIGN

Prospective cohort study of data collected at baseline, 3 and 6 months from HIV-infected patients with a history of injection drug use who were not treated with anti-retroviral therapy. Participants were recruited between 2012-2014 from a narcology (addiction) hospital in St. Petersburg, Russia.

METHODS

Fatal overdose was determined based on contact reports to study staff in the year after discharge. Non-fatal overdose was self-reported at the 3- and 6-month assessments. The main independent variable for HIV severity was CD4 cell count at the baseline interview (<200cells/mm³≥200cells/mm³). Secondary analyses assessed time since HIV diagnosis and treated with anti-retroviral treatment (ART) prior to enrolment as independent variables. We fit Cox proportional hazards models to assess whether HIV severity is associated with either fatal or non-fatal overdose.

RESULTS

Among 349 narcology patients, 18 participants died from overdose within one year after discharge (8.7%, 95% CI 3.4-14.2 by Kaplan-Meier); an estimated 51% [95% CI 34-68%] reported at least one non-fatal overdose within 6 months of discharge. HIV severity, time since HIV diagnosis and ever ART were not significantly associated with either fatal or non-fatal overdose events.

CONCLUSION

Fatal and non-fatal overdose are common among Russians living with HIV/AIDS who inject drugs after narcology hospital discharge. Overdose prevention interventions are urgently warranted among Russian narcology patients with HIV infection.

Mortality of Hospitalized Drug Users in the Czech Republic

Drug users are generally thought to experience higher mortality rates than those found among the general population. This study analyzes mortality rates among different subgroups of drug users in the Czech Republic. For this project, a retrospective cohort mortality study was conducted. A cohort of 12,207 persons aged 15 to 49 who had been hospitalized for drug related behavioral disorders was followed from 1997 to 2002. The study findings indicate that direct standardized mortality for the cohort of drug users was 16.78 per 1000 person-years (PY); 22.38 for men and 11.18 per 1000 PY for women. After reaching a peak in 1998, mortality rates began to decrease and stabilized around 14 per 1,000 PY from 2000 to 2002. When compared to the rates found in the general population, drug user mortality is eight times higher than nonuser rates (SMR = 8.15; 8.13 for men and 8.22 for women). These mortality rates are highest among polyvalent drug and opiate users and lowest among stimulant users. The authors conclude that the overall mortality of opiate users in the Czech Republic is relatively low when compared with those reported in similar European and non-European studies. There were few overdoses found in the cohort, and in sharp contrast to other available studies, no AIDS related cases were observed.

Effectiveness of Methadone Maintenance Therapy and Improvement in Quality of Life Following a Decade of Implementation

Methadone maintenance therapy has been found to be an effective harm reduction treatment for opioid use disorder. However evidence of its benefits over a longer duration of treatment is limited as most studies focus on its short term benefits. As methadone maintenance therapy reaches a decade since its implementation in Malaysia, this study sought to examine the effectiveness of methadone treatment, change in quality of life among patients since entry to methadone treatment, as well as factors predicting the magnitude of change in quality of life. This study found that methadone maintenance therapy was effective in reducing heroin use, injecting practices and crime, and in improving in social functioning and physical symptoms, but not in reducing sex-related HIV risk-taking behavior. Though patients had a significantly better quality of life at follow-up than at entry to methadone maintenance therapy, the improvement in quality of life was not significantly greater as the duration of treatment increased. Age above 50 years old, human immunodeficiency virus (HIV) positive status and physical symptoms predicted a poorer improvement in quality of life between baseline and follow-up. On the other hand, patients with hepatitis B showed a greater improvement in quality of life in the social relationships domain compared to patients without hepatitis B. In conclusion, methadone maintenance therapy is an effective treatment for opioid use disorder and improves quality of life but its benefits in further improving quality of life beyond a decade of treatment need further evaluation.