Key findings from the WHO collaborative study on substitution therapy for opioid dependence and HIV/AIDS

The impact of emergency guidance to the COVID-19 pandemic on treatment entry, retention and mortality among patients on methadone in Ukraine

BACKGROUND AND AIMS

Ukraine's Ministry of Health released urgent COVID-19 guidelines, allowing for early implementation of take-home dosing (THD) for opioid agonist therapies (OAT) such as methadone. Enrollment in OAT and retention in the program are the most effective HIV prevention strategies for people who inject drugs (PWID). This study aimed to evaluate the impact of Ukraine's COVID-19 emergency guidance on OAT treatment enrollment, retention on treatment and mortality.

DESIGN AND SETTING

Using Ukraine's national OAT registry for 252 governmental clinics across 25 regions, we conducted a 12-month comparative prospective cohort survival analysis. This study compared newly enrolled methadone patients within the initial 6 months following the COVID-19 guidance (COVID) with patients from the preceding year (pre-COVID) in a country with high adult HIV prevalence (1.2%) that is concentrated in PWID.

PARTICIPANTS

In the nation-wide sample of newly enrolled PWID in Ukraine, comprising 2798 individuals, 1423 were in the COVID cohort and 1375 were in the pre-COVID cohort. The majority were male (86.7%), with an average age of 39.3 years.

MEASUREMENTS

Primary outcomes were average monthly enrollment per cohort, treatment retention and mortality, with internal time-dependent predictors, including THD and optimal (> 85 mg) methadone dosing.

RESULTS

Relative to the pre-COVID period, the monthly average patient enrollment was statistically significantly higher during the COVID period (283.7 versus 236.0; P < 0.0001), where patients were more likely to transition to THD and achieve optimal dosing earlier. Significant differences were observed in the proportions of person-months on THD (41 versus 13%, P < 0.0001) and optimal dosing (38 versus 31%, P < 0.0001) between the COVID and pre-COVID cohorts. Predictors of treatment retention, expressed as adjusted hazard ratios (aHR), included early THD [aHR = 1.90, 95% confidence interval (CI) = 1.47-2.45], early optimal dosing (aHR = 1.71, 95% CI = 1.37-2.13) and prior methadone treatment (aHR = 1.39, 95% CI = 1.15-1.68). These factors persisted, respectively, in the pre-COVID (aHR = 2.28, 95% CI = 1.41-3.70; aHR = 1.84, 95% CI = 1.32-2.56; and aHR = 1.36, 95% CI = 1.06-1.74) and COVID (aHR = 1.91, 95% CI = 1.40-2.59; aHR = 1.61, 95% CI = 1.20-2.16; and aHR = 1.49, 95% CI = 1.08-1.94) cohorts. Survival did not differ significantly between the two prospective cohorts.

CONCLUSION

Ukraine's prompt adoption of early take-home dosing for opioid agonist therapies, such as methadone, following the emergency COVID-19 guidance appears to have increased enrollment into methadone and improved treatment retention for people who inject drugs without adverse effects on patient survival.

A novel tramadol-polycaprolactone implant could palliate heroin conditioned place preference and withdrawal in rats: behavioral and neurochemical study

Drug dependence is a chronic brain disease characterized by craving and recurrent episodes of relapse. Tramadol HCl is a promising agent for withdrawal symptoms management, considering its relatively low abuse potential and safety. Oral administration, however, is not preferred in abstinence maintenance programs. Introducing an implantable, long-lasting formula is suggested to help outpatient abstinence programs achieve higher rates of treatment continuation. Tramadol implants (T350 and T650) were prepared on polycaprolactone polymer ribbons by the wet method. Male Wistar rats were adapted to heroin-conditioned place preference (CPP) at escalating doses (3-30 mg/kg, intraperitoneally, for 14 days). Implants were surgically implanted in the back skin of rats. After 14 days, the CPP score was recorded. Naloxone (1 mg/kg, intraperitoneally) was used to induce withdrawal on day 15, and symptoms were scored. Elevated plus maze and open field tests were performed for anxiety-related symptoms. Striata were analyzed for neurochemical changes reflected in dopamine, 3,4-dihydroxyphenyl acetic acid, gamma-aminobutyric acid, and serotonin levels. Brain oxidative changes including glutathione and lipid peroxides were assessed. The tramadol implants (T350 and T650) reduced heroin CPP and limited naloxone-induced withdrawal symptoms. The striata showed increased levels of 3,4-dihydroxyphenyl acetic acid, and serotonin and decreased levels of gamma-aminobutyric acid and dopamine after heroin withdrawal induction, which were reversed after implanting T350 and T650. Implants restore the brain oxidative state. Nonsignificant low naloxone-induced withdrawal score after the implant was used in naive subjects indicating low abuse potential of the implants. The presented tramadol implants were effective at diminishing heroin CPP and withdrawal in rats, suggesting further investigations for application in the management of opioid withdrawal.

The test-retest reliability of the Opiate Treatment Index in nyaope users in Johannesburg

Background

Epidemiological studies suggest that nyaope, a heroin-based drug, is widely used in South Africa. Yet few reliable research tools are available to assess treatment outcomes of users. The Opiate Treatment Index (OTI), a tool developed in Australia, could potentially facilitate research on context-specific South African treatment outcomes. However, we know little of its test-retest reliability.

Aim

This study aimed to assess the test-retest reliability of the OTI among a sample of nyaope users in Johannesburg.

Setting

This study was conducted across three substance use treatment facilities in Johannesburg.

Methods

The OTI was administered to 53 nyaope users at baseline and one week later. To determine the test-retest reliability of the OTI, the intra-class correlation coefficients (ICC) and the Brennan-Prediger coefficients of the two interviews were calculated.

Results

The ICC of the Q-scores from the data sets along with the Brennan-Prediger coefficient for the substance use domain were calculated. The ICC for nyaope was 0.38. Brennan-Prediger coefficients were as follows: alcohol - 0.96, crack-cocaine - 0.89, cannabis - 0.92, methaqualone - 0.85 and crystal methamphetamine - 0.89.

Conclusion

A significant positive finding was the excellent test-retest reliability of the injecting and sexual behaviour domains and moderate reliability of the criminality, general health and social functioning domains.

Contribution

The results of this study provide insight into the reliability of this tool and for its use in future studies in the South African context.

Navigating Adherence: Unraveling Factors Shaping Opioid Substitution Therapy Compliance

Background and objective In drug-deaddiction programs, dropout is a major problem in any drug de-addiction program, as dependence is a chronic illness known to relapse frequently. Understanding factors that predict dropout can help design targeted interventions to promote follow-up. This study aimed to assess the various sociodemographic characteristics of opioid-dependent subjects on buprenorphine maintenance treatment and dropping out at or before the three-month follow-up period. Method In this study, the sociodemographic characteristics and quality of life (QOL) of 34 opioid-dependent subjects (males, 32, 94%; females, 2, 6%) on the day of their enrolment in an opioid substitution therapy (OST) center were assessed, and a comparison of sociodemographic and drug use pattern was made between those who followed up and those who dropped out by the end of three months. Results Statistical analysis of the various sociodemographic characteristics using appropriate tests yielded that predictors of good follow-up are younger age (F = 4.57907, P = 0.04008), better education (F = 5.07221, P = 0.031305), and being part of a nuclear family. Longer follow-up was associated with shorter opioid intake duration (F = 8.58908, P = 0.006195). Better social relationships, as evidenced by the social relationship domain score of QOL, predicted longer follow-up (F = 8.58908, P = 0.006195). Other characteristics analyzed did not yield significant associations. Conclusions The study unveils the complexity of opioid addiction recovery, revealing the interplay of age, education, family, addiction duration, and support, shaping one's resilience in recovery.

Male patients' preferences for opioid use treatment programs

BACKGROUND

A patient-centered approach to the treatment of substance use is helpful in achieving positive treatment outcomes. This study aimed to explore male patients' preferences for opioid use treatments.

METHODS

A qualitative study was conducted in Isfahan, a city in the center of Iran. The study sample included 64 male participants who had started treatment for opioid use disorder (OUD). Using a purposive maximum variation sampling procedure, seven treatment centers were selected as interview venues. The semi-structured face-to-face interviews were conducted in a private room in the selected centers. A hybrid inductive/deductive approach was used to thematize the interview transcripts.

RESULTS

A total of three themes and 13 subthemes on opioid treatment preferences were identified: treatment concerns (anonymity, social stigma, fear of treatment distress, and family concerns), treatment attributes (treatment cost, location of the treatment center, treatment period, frequency of attendance, informed treatment, and treatment personnel), and treatment type (maintenance or abstinence and residential and community treatments). The study showed that all treatment programs were perceived to have their own strengths and weaknesses.

CONCLUSIONS

The results showed that patients with OUD carefully compare the positive and negative aspects of existing treatment programs, and they consider a treatment program to be a package of favorable and non-favorable qualities. The identified themes could inform policymakers about the treatment preferences of male patients and provide an opportunity to promote better treatment options for OUD.

Differential effect of cannabis use on opioid agonist treatment outcomes: Exploratory analyses from the OPTIMA study

INTRODUCTION

Conflictual evidence exists regarding the effects of cannabis use on the outcomes of opioid agonist therapy (OAT). In this exploratory analysis, we examined the effect of recent cannabis use on opioid use, craving, and withdrawal symptoms, in individuals participating in a trial comparing flexible buprenorphine/naloxone (BUP/NX) take-home dosing model to witnessed ingestion of methadone.

METHODS

We analyzed data from a multi-centric, pragmatic, 24-week, open label, randomized controlled trial in individuals with prescription-type opioid use disorder (n = 272), randomly assigned to BUP/NX (n = 138) or methadone (n = 134). The study measured last week cannabis and opioid use via timeline-follow back, recorded at baseline and every two weeks during the study. Craving symptoms were measured using the Brief Substance Craving Scale at baseline, and weeks 2, 6, 10, 14, 18 and 22. The study measured opioid withdrawal symptoms via Clinical Opiate Withdrawal Scale at treatment initiation and weeks 2, 4, and 6.

RESULTS

The mean maximum dose taken during the study was 17.3 mg/day (range = 0.5-32 mg/day) for BUP/NX group and 67.7 mg/day (range = 10-170 mg/day) in the methadone group. Repeated measures generalized linear mixed models demonstrated that cannabis use in the last week (mean of 2.3 days) was not significantly associated with last week opioid use (aβ ± standard error (SE) = -0.06 ± 0.04; p = 0.15), craving (aβ ± SE = -0.05 ± 0.08, p = 0.49), or withdrawal symptoms (aβ ± SE = 0.09 ± 0.1, p = 0.36). Bayes factor (BF) for each of the tested models supported the null hypothesis (BF < 0.3).

CONCLUSIONS

The current study did not demonstrate a statistically significant effect of cannabis use on outcomes of interest in the context of a pragmatic randomized-controlled trial. These findings replicated previous results reporting no effect of cannabis use on opioid-related outcomes.

The Role of Physical Exercise in Opioid Substitution Therapy: Mechanisms of Sequential Effects

It is generally accepted that chronic opioid use is associated with structural and functional changes in the human brain that lead to an enhancement of impulsive behavior for immediate satisfaction. Interestingly, in recent years, physical exercise interventions have been used as an adjunctive treatment for patients with opioid use disorders (OUDs). Indeed, exercise has positive effects on both the biological and psychosocial basis of addiction, modifying neural circuits such as the reward, inhibition, and stress systems, and thus causing behavioral changes. This review focuses on the possible mechanisms that contribute to the beneficial effects of exercise on the treatment of OUDs, with emphasis placed on the description of a sequential consolidation of these mechanisms. Exercise is thought to act initially as a factor of internal activation and self-regulation and eventually as a factor of commitment. This approach suggests a sequential (temporal) consolidation of the functions of exercise in favor of gradual disengagement from addiction. Particularly, the sequence in which the exercise-induced mechanisms are consolidated follows the pattern of internal activation-self-regulation-commitment, eventually resulting in stimulation of the endocannabinoid and endogenous opioid systems. Additionally, this is accompanied by modification of molecular and behavioral aspects of opioid addiction. Overall, the neurobiological actions of exercise in combination with certain psychological mechanisms appear to promote its beneficial effects. Given the positive effects of exercise on both physical and mental health, exercise prescription is recommended as a complement to conventional therapy for patients on opioid maintenance treatment.

The development and initial validation of the Russian version of the BASIS-24

BACKGROUND

Efficient and linguistically appropriate instruments are needed to assess response to addiction treatment, including severity of addiction/mental health status. This is critical for Russian-speaking persons in Eastern Europe and Central Asia (EECA) where Medications for Opioid Use Disorder (MOUD) remain underscaled to address expanding and intertwined opioid, HIV, HCV and tuberculosis epidemics. We developed and conducted a pilot validation of a Russian version of the 24-item Behavior and Symptom Identification Scale (BASIS-24), an addiction/mental health severity instrument with six subscales, previously validated in English.

METHODS

Using the Mapi approach, we reviewed, translated, and back-translated the content to Russian, pilot-tested the Russian-version (BASIS-24-R) among new MOUD patients in Ukraine (N = 283). For a subset of patients (n = 44), test-rest was performed 48 h after admission to reassess reliability of BASIS-24-R. Exploratory principal component analysis (PCA) assessed underlying structure of BASIS-24-R.

RESULTS

Cronbach alpha coefficients for overall BASIS-24-R and 5 subscales exceeded 0.65; coefficient for Relationship subscale was 0.42. The Pearson correlation coefficients for overall score and all subscales on the BASIS-24-R exceeded 0.8. Each item loaded onto factors that corresponded with English BASIS-24 subscales ≥ 0.4 in PCA.

CONCLUSION

Initial version of BASIS-24-R appears statistically valid in Russian. Use of the BASIS-24-R has potential to guide MOUD treatment delivery in the EECA region and help to align addiction treatment with HIV prevention goals in a region where HIV is concentrated in people who inject opioids and where healthcare professionals have not traditionally perceived MOUD as effective treatment, particularly for those with mental health co-morbidities.

The intergenerational persistence of opioid dependence: Evidence from administrative data

To address the opioid crisis, it is crucial to understand its origins. We provide descriptive evidence for the intergenerational persistence of opioid dependence. Our analysis is based on administrative data covering the universe of Austrian births from 1984 to 1990. We consider prescription opioids and a new proxy for addiction to illicit opioids. We find that, if at least one parent is using illicit opioids, the likelihood of the child using increases from 1% to 7%. For prescription opioids, we observe an increase from 3.6% to 6.7%. Both associations are stable and do not change when controlling for environmental variables.

Consensus recommendations for opioid agonist treatment following the introduction of emergency clinical guidelines in Ireland during the COVID-19 pandemic: A national Delphi study

BACKGROUND

Emergency contingency guidelines for opioid agonist treatment (OAT) were introduced in Ireland in March 2020, to ensure rapid and uninterrupted access to treatment while mitigating COVID-19 risk. The contingency guidelines deviated, across multiple clinical domains, from pre-pandemic clinical guidelines published in 2016. The objectives of this study are to (1) identify changes introduced to OAT clinical guidelines in Ireland during the pandemic; and (2) develop consensus on whether the new recommendations should be retained beyond the pandemic, using a national Delphi consensus methodology.

METHODS

Clinical guidance recommendations ('statements') were generated by comparing the newly established contingency guidelines with the national 2016 Clinical Guidelines for OAT. Over two rounds of on-line Delphi testing, a panel of experts (people currently accessing OAT, psychiatrists, general practitioners, community pharmacists, a nurse, a psychologist and support/key workers) independently rated their agreement with each statement and provided comments. Statements with a median score of 4 or 5 and a lower quartile of ≥4 were classified as having reached consensus.

RESULTS

Forty-eight panel members were recruited, with a high participation level at Round 2 (90%, n=43). Consensus was achieved for 12 of the 19 statements at Round 1. The 7 remaining statements were revised, with 2 new statements, resulting in 9 statements at Round 2. Four statements reached consensus at Round 2. The final list includes 16 clinical guidance statements; 9 relating to assessment, 3 to OAT drug choice and dosing, 1 to take-away doses, 2 to overdose prevention and 1 to the continuation of e-prescriptions.

CONCLUSIONS

A wide range of stakeholders involved in the delivery and receipt of OAT agreed on 16 clinical guidance statements for inclusion in OAT clinical guidelines as we move beyond the pandemic, rather than reverting to pre-pandemic guidelines. The agreed statements relate to facilitating safe access to OAT with minimal waiting time, supporting patient-centred care to promote health and well-being, and preventing drug overdose. Notably, consensus was not achieved for OAT drug dosage and frequency of urine testing during the stabilisation and maintenance phase of care.

A pilot implementation study to scale-up methadone in incarcerated persons with opioid use disorder and retain them on treatment after release in Moldova

BACKGROUND

Eastern Europe and Central Asia have intertwined HIV and incarceration epidemics, concentrated in people who inject drugs. Moldova is one of the few countries in this region that offers methadone within prisons, but uptake and post-release retention remains suboptimal. Screening, brief intervention, and referral to treatment (SBIRT) procedures are a potential implementation strategy to address this problem.

METHODS

From June 1, 2017 to March 3, 2018, we conducted a 2-stage SBIRT strategy in nine prisons and four pre-trial detention facilities in Moldova among incarcerated persons with opioid use disorder (OUD; N = 121) and within 90 days of release. Survey results were analyzed to evaluate the effect of the SBIRT strategy on the uptake of and post-release retention on methadone maintenance treatment (MMT).

RESULTS

Among the 121 screened with OUD, 27 were on MMT at baseline within the prison and this number increased to 41 after the two-step SBIRT intervention, reflecting a 51.9% increase over baseline. Eleven (78.6%) of the 14 participants that newly started MMT did so only after completing both SBIRT sessions. The brief intervention did not significantly improve knowledge about methadone but did improve attitudes towards it. Among the 41 participants who received methadone during this trial, 40 (97.6%) were retained 6 months after release; the one participant not retained was on methadone at the time of the intervention and had planned to taper off.

CONCLUSION

The SBIRT strategy significantly improved participant attitudes, but treatment initiation mostly occurred after completing both sessions, including soon after release, but remained low overall. Work within the Moldovan prison subculture to dispel negative myths and misinformation is needed to further scale-up OAT in Moldova.

Medication for opioid use disorder in the Arab World: A systematic review

BACKGROUND

Opioid use disorder (OUD) is a global public health concern. The standard of care for OUD involves treatment using medications such as buprenorphine, methadone, or naltrexone. No known review exists to assess the contextual factors associated with medication for opioid use disorder (MOUD) in the Arab World. This systematic review serves as an implementation science study to address this research gap and improve the uptake of MOUD in the Arab World.

METHODS

Systematic searches of Medline, PsycINFO, and EMBASE, and a citation analysis, were used to identify peer-reviewed articles with original data on MOUD in the Arab World. Quality assessment was conducted using the CASP appraisal tools, and main findings were extracted and coded according to the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework.

RESULTS

652 research articles were identified, and 10 met inclusion criteria for final review. Four studies considered health-systems aspects of MOUD administration, such as cost-effectiveness, the motivations for and impact of national MOUD policies, the types of social, political, and scientific advocacy that led to the adoption of MOUD in Arab countries, and the challenges limiting its wide-scale adoption in the Arab World. Six papers considered MOUD at individual and group patient levels by evaluating patient quality of life, addiction severity, patient satisfaction, and patient perspectives on opioid agonist therapy.

CONCLUSION

Despite financial and geographic barriers that limit access to MOUD in the Arab World, this review found MOUD to be cost-effective and associated with positive health outcomes for OUD patients in the Arab World. MOUD can be successfully established and scaled to the national level in the Arab context, and strong coalitions of health practitioners can lobby to establish MOUD programs in Arab countries. Still, the relative novelty of MOUD in this context precludes an abundance of research to address its long-term delivery in the Arab World.

Prevalence and correlates of suicide attempts in high-risk populations: a cross-sectional study among patients receiving opioid agonist therapy in Norway

BACKGROUND

Death by suicide in patients enrolled in opioid agonist therapy (OAT) is a major clinical concern. However, little knowledge exists regarding suicide attempts in this patient group. This study presents the lifetime prevalence of suicide attempts and the associations between suicide attempts and clinical and sociodemographic variables such as education, sex, early onset of substance use (< 13 years of age), substance use patterns, and injecting substance use among patients receiving OAT.

METHODS

We used data from a cohort of OAT patients in Norway obtained from a health assessment of self-reported suicide attempts and sociodemographic and clinical factors. A total of 595 patients receiving OAT were assessed from 2016 to 2020. A binary logistic regression analysis was performed and reported with an unadjusted odds ratio and 95% confidence intervals (OR). The purpose of this assessment was to analyze associations between suicide attempts and substance use patterns as well as the injection of substances during the 30 days leading up to the health assessment. A negative binomial regression analysis with an incidence rate ratio and 95% confidence intervals (IRR) was performed to investigate sex, education, early onset of substance use, and the number of suicide attempts.

RESULTS

Forty-one percent of the OAT patients had attempted to die by suicide at least once during their lifetime. An early onset of substance use was strongly associated with the suicide attempts (IRR: 1.7, 1.3-2.2). No significant association was found between suicide attempts and sex (IRR: 1.2, 0.9-1.6) or education (IRR: 0.6, 0.2-2.1). Likewise, no association was identified between suicide attempts and injecting substance use (OR: 0.9, 0.6-1.3), nor using alcohol (OR: 0.9, 0.7-1.3), amphetamines (OR: 1.0, 0.7-1.3), benzodiazepines (OR: 1.0, 0.7-1.4), cannabis (OR: 1.2, 0.9-1.7), cocaine (OR: 1.3, 0.6-3.0), or opioids (OR: 1.4, 0.9-2.0).

CONCLUSION

The lifetime prevalence of suicide attempts was alarmingly high in the OAT population. An early onset of substance use seemed to be an important risk factor for suicide attempts. There was a non-significant association to more current use of opioids among OAT patients with previous suicide attempts.

Looking beyond the opioid receptor: A desperate need for new treatments for opioid use disorder

The mainstay of treatment for opioid use disorder (OUD) is opioid agonist therapy (OAT), which modulates opioid receptors to reduce substance craving and use. OAT maintains dependence on opioids but helps reduce overdose and negative sequelae of substance abuse. Despite increasing availability of OAT, its effectiveness is limited by difficulty in initiating and maintaining patients on treatment. With the worsening opioid epidemic in the United States and rising overdose deaths, a more durable and effective treatment for OUD is necessary. This paper reviews novel treatments being investigated for OUD, including neuromodulatory interventions, psychedelic drugs, and other novel approaches. Neuromodulatory interventions can stimulate the addiction neural circuitry involving the dorsolateral prefrontal cortex and deeper mesolimbic structures to curb craving and reduce use, and multiple clinical trials for interventional treatment for OUD are currently conducted. Similarly, psychedelic agents are being investigated for efficacy in OUD specifically. There is a resurgence of interest in psychedelic agents' therapeutic potential, with evidence of improving mood symptoms and decreased substance use even after just one dose. Exact mechanism of their anti-addictive effect is not fully elucidated, but psychedelic agents do not maintain opioid dependence and some may even be helpful in abating symptoms of withdrawal. Other potential approaches for OUD include targeting different parts of the dopamine-dependent addiction pathway, identifying susceptible genes and modulating gene products, as well as utilizing vaccines as immunotherapy to blunt the addictive effects of substances. Much more clinical data are needed to support efficacy and safety of these therapies in OUD, but these proposed novel treatments look beyond the opioid receptor to offer hope for a more durably effective OUD treatment.

Availability of opioid agonist treatment and critical incidents in Forensic Clinics for Dependency Diseases in Germany

BACKGROUND

Prevalence of substance use disorders, especially opioid use disorders, is high in patients admitted into forensic psychiatric settings. Opioid agonist treatment is a safe, well-established, and effective treatment option for patients that suffer from opioid dependence. Surprisingly, data on the availability and practice of opioid agonist treatment (OAT) options in German Forensic Clinics for Dependency Diseases is rare. Furthermore, essential data on the prevalence of critical incidents such as violent behavior, relapse, or escape from the clinic are missing for this particular treatment setting.

MATERIALS AND METHODS

We conducted an observational study on all forensic addiction treatment units in Germany (Sect. 64 of the German Criminal Code). A questionnaire on the availability and practice of OAT was sent to all Forensic Clinics for Dependency Diseases in Germany. Following items were assessed: availability and the total number of patients that received an OAT in 2018, available medication options, specific reasons for start and end of OAT, number of treatments terminated without success, number of successful treatments, and critical incidents such as violent behavior, relapse, escape and reoffending. We compared the forensic clinics that offered OAT with those that did not offer this treatment option. The data were analyzed descriptively. Mean and standard deviation was calculated for metric scaled variables. For categorical variables, absolute and relative frequencies were calculated. The two groups (OAT vs. Non-OAT institutions) were compared concerning the given variables by either using Fishers exact test (categorical variables), t-test (normally distributed metric variables), or Wilcoxon-test (metric variables not normally distributed).

RESULTS

In total, 15 of 46 Forensic Clinics for Dependency Diseases participated in the study (33%). In total, 2,483 patients were treated in the participating clinics, 18% were relocated into prison due to treatment termination, and 15% were discharged successfully in 2018. 275 critical incidents were reported: violence against a patient (4%), violence against staff (1.6%), escape (4.7%) and reoffending in (0.5%). In seven clinics treating 1,153 patients, an OAT was available. OAT options in forensic clinics were buprenorphine/naloxone, buprenorphine, methadone, and levomethadone. Regarding critical incidents and successful discharge, no differences were detected in the clinics with or without an OAT. In the clinics that offered an OAT, we found a significantly higher rate of treatment termination without success (p < 0.007) in comparison to clinics without an OAT program. Ninety-nine patients received an OAT, and this treatment was ended due to illegal drug abuse (57%), refusal to give a urine drug sample (71%), and cases where the OAT was given away to other patients (85%).

CONCLUSION

In Forensic Clinics for Dependency Diseases in Germany, OAT is not available in every institution, and thus, access is limited. Critical incidents such as violent behavior against staff or patients and escape are not uncommon in these forensic treatment settings. Further studies are needed to enhance the understanding of OAT practice and the risks for patients and staff.

Facilitators of and barriers to buprenorphine initiation for people with opioid use disorder in the emergency department: protocol for a scoping review

INTRODUCTION

Buprenorphine-naloxone is recommended as a first-line agent for the treatment of opioid use disorder. Although initiation of buprenorphine in the emergency department (ED) is evidence based, barriers to implementation persist. A comprehensive review and critical analysis of both facilitators of and barriers to buprenorphine initiation in ED has yet to be published. Our objectives are (1) to map the implementation of buprenorphine induction pathway literature and synthesise what we know about buprenorphine pathways in EDs and (2) to identify gaps in this literature with respect to barriers and facilitators of implementation.

METHODS AND ANALYSIS

We will conduct a scoping review to comprehensively search the literature, map the evidence and identify gaps in knowledge. The review will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols Extension for Scoping Reviews and guidance from the Joanna Briggs Institution for conduct of scoping reviews. We will search Medline, APA, PsycINFO, CINAHL, Embase and IBSS from 1995 to present and the search will be restricted to English and French language publications. Citations will be screened in Covidence by two trained reviewers. Discrepancies will be mediated by consensus. Data will be synthesised using a hybrid, inductive-deductive approach, informed by the Consolidated Framework for Implementation Research as well as critical theory to guide further interpretation.

ETHICS AND DISSEMINATION

This review does not require ethics approval. A group of primary knowledge users, including clinicians and people with lived experience, will be involved in the dissemination of findings including publication in peer-reviewed journals. Results will inform future research, current quality improvement efforts in affiliated hospitals, and aide the creation of a more robust ED response to the escalating overdose crisis.

Examining a migration-based phenomenon of heroin use in an urban drug scene in Sao Paulo, Brazil

Purpose

Brazil’s street-based drug use is mostly characterized by non-injection psychostimulant (e.g. crack-cocaine) drug use in Brazil, with limited interventions and service availability. Recently, an influx of multi-ethnic migrants within an urban drug scene in Sao Paulo was associated with heroin use, a drug normatively absent from Brazil. The purpose of this paper is to characterize and compare heroin use-related characteristics and outcomes for an attending sub-sample of clients from a large community-based treatment centre (“CRATOD”) serving Sao Paulo’s local urban drug scene.

Design/methodology/approach

All non-Brazilian patients (n = 109) receiving services at CRATOD for 2013–2016 were identified from patient files, divided into heroin users (n = 40) and non-heroin users (n = 69). Based on chart reviews, select socio-demographic, drug use and health status (including blood-borne-virus and other infections per rapid test methods) were examined and bi-variately compared. Multi-variate analyses examined factors independently associated with heroin use.

Findings

Most participants were male and middle-aged, poly-drug users and socio-economically marginalized. While heroin users primarily originated from Africa, they reported significantly more criminal histories, drug (e.g. injection) and sex-risk behaviors and elevated rates of BBV (e.g. Hepatitis C Virus and HIV). A minority of heroin users attending the clinic was provided methadone treatment, mostly for detoxification.

Originality/value

This study documented information on a distinct sample of mostly migration-based heroin users in Sao Paulo, Brazil. Based on the local experience, global migration dynamics can bring changes to established drug use cultures and services, including new challenges for drug use-related related behaviors and therapeutic interventions that require effective understanding and addressing.

Changes in substance use during outpatient treatment for substance use disorders: a prospective Norwegian cohort study from 2016 to 2020

Background

Continuous use of amphetamines, alcohol, benzodiazepines, cannabis, cocaine, or opioids contributes to health impairments, increased morbidity, and overdose deaths among patients with substance use disorders (SUDs). This study evaluates the impact of inpatient detoxification, injecting substance use, age, and gender on substance use over time among patients undergoing outpatient SUD treatment.

Methods

We used data from a cohort of SUD patients in Norway obtained from health assessments of self-reported substance use and sociodemographic and clinical factors. A total of 881 substance use measurements, including substances and frequency of use, were assessed for 708 SUD patients in 2016–2020. Of those, 171 patients provided two or more substance use measurements. The total substance use was calculated, creating a substance use severity index (SUSI), ranging from zero (no use) to one (daily use of all substances). We defined baseline as the first substance use measurement when the measurements were listed chronologically. Time was defined as years from baseline. We used a linear mixed model to analyze the SUSI at baseline and over time, and its associations with inpatient detoxification, injecting substance use, gender, and age, presented with coefficients and 95% confidence intervals (CI).

Results

No longitudinal changes in the SUSI were found compared with baseline (change in SUSI (cSUSI): 0.04, 95% CI: − 0.05;0.13, p = 0.397). Likewise, “inpatient detoxification” was not associated with changes in the SUSI compared with “no inpatient detoxification” (cSUSI: 0.00, 95% CI: − 0.04;0.04, p = 0.952). However, injecting substances were associated with a higher SUSI than not injecting substances at baseline (difference in SUSI: 0.19, 95% CI: 0.16;0.21, p = < 0.001), and starting to inject substances was associated with increasing SUSI over time compared with not starting to inject substances (cSUSI: 0.11, 95% CI: 0.07;0.15, p = < 0.001). Gender was not significantly associated with changes in the SUSI (cSUSI: − 0.04, 95% CI: − 0.07;0.00, p = 0.052), while patients over 60 years of age had a lower SUSI than those under the age of 30 at baseline (difference in SUSI: − 0.08, 95% CI: − 0.14;− 0.01, p = 0.018), with no change over time (cSUSI: − 0.05, 95% CI: − 0.16;0.05, p = 0.297).

Conclusion

The present study demonstrates that inpatient detoxification was not associated with substance use changes over time for patients undergoing outpatient SUD treatment. Otherwise, injecting substance use was a particular risk factor for a high level of substance use. Future research needs to evaluate the impact of other treatment approaches on substance use, ideally in randomized controlled trials.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-021-00403-9.

Successful transfer of stable patients on opioid agonist therapies from specialty addiction treatment to primary care settings in Ukraine: A pilot study

INTRODUCTION

In Ukraine, HIV is concentrated among people who inject drugs (PWID), and opioid agonist therapies (OAT) are the most effective approach to preventing HIV transmission. OAT coverage is well below internationally recommended levels, with OAT provided primarily in specialty addiction treatment clinics. Integrating OAT into primary care settings represents a promising practice for increasing OAT coverage.

METHODS

The study collected data prospectively from the first 50 stable patients transferred from the largest OAT site to 10 primary care clinics in Kiev; patients had negative urine drug tests for the previous six months. Participants completed the BASIS-24-the 24-item Behaviour and Symptom Identification Scale-to assess symptoms of psychiatric and social function across 6 domains: (1) depression and functioning, (2) relationships, (3) self-harm, (4) emotional lability, (5) psychosis, and (6) substance use before transfer and 6 months after transfer from May through November 2019.

RESULTS

Participants were on average 36 years old, mostly male (84.0%) and had some employment (64.0%). After six months, some employment increased to 88.0% and BASIS-24 scores significantly improved on four domains: depression (1.09 vs 0.73, p = 0.0005), relationships (2.15 vs 1.7, p < 0.0001), emotional liability (1.30 vs 1.00, p = 0.0209) and substance use (1.23 vs 1.07, p = 0073).

CONCLUSIONS

Stable OAT patients can be successfully transferred from specialty to primary care clinics without deterioration in mental health symptoms or functioning. Patients transferred to primary care showed significant improvement in their emotional well-being, their substance use, and their employment status.

Impact of the COVID-19 pandemic on opioid agonist treatment in Ireland: Protocol for an interrupted time series analysis

While opioid agonist treatment (OAT) is the most effective treatment for opioid dependence, it is heavily dependent on regular face-to-face healthcare delivery placing both clients and treatment providers at risk of COVID-19. Following the emergence of COVID-19, policies were rapidly changed in Ireland, with the introduction of national contingency guidelines by the HSE National Social Inclusion Office, beginning in March 2020 to ensure rapid and uninterrupted access to OAT while balancing efforts to mitigate COVID-19 risk. This study aims to assess the impact of the national contingency guidelines, on the quality of OAT care delivered in Ireland. An interrupted time series analysis will be conducted using anonymised aggregated level data obtained from the Central Treatment List (CTL), the national register of people receiving OAT, administered by the National Drug Treatment Centre Board on behalf of the HSE. Separate segmented regressions will be conducted to estimate the impact of the national contingency guidelines on the following outcomes: (1) number of patients in treatment; (2) number of patients starting OAT; (3) average waiting time for treatment; (4) number of people on waiting list; (5) number of patients dropping out of treatment.  The study period will be divided into pre-(March 2019 to February 2020) and post- intervention (April 2020 to March 2021) segments. Immediate (change in level) and longer-term impacts (change in slope) of changes to provision of OAT in each of the outcomes will be investigated. Regression coefficients (β) and 95% confidence intervals (CIs) will be reported.

Development of quality indicators for the continued and safe delivery of Opioid Agonist Treatment (OAT), throughout and beyond COVID-19, using a Delphi Consensus technique

Opioid agonist treatment (OAT) is the most effective treatment for opioid dependence, although it relies heavily on regular face-to-face healthcare delivery. Following the emergence of COVID-19, policies were rapidly changed in Ireland to reduce the risk of contracting the virus for both clients and treatment providers. From March 2020, the Health Service Executive (HSE) National Social Inclusion Office introduced a series of national contingency guidelines, to ensure fast and uninterrupted access to OAT while balancing efforts to mitigate COVID-19 risks. The Programme for Government 2020 states they will retain many of the measures introduced during the COVID-19 pandemic to reduce waiting times in accessing treatment services and reduce overdose mortality. It is therefore essential to examine the impacts, benefits and unintended consequences of the special measures introduced during COVID-19 at a national level, thus informing which measures can and should be sustained throughout and beyond COVID-19 to support effective, safe and patient-centered care promoting the health and wellbeing of all people with opioid dependence. The aim of this project is to identify priorities for quality improvements which will inform clinical decision making throughout and beyond the pandemic. This will be achieved through a Delphi consensus study. Quality indicators will be identified by comparing the national contingency guidelines with the national 2016 Clinical Guidelines. The project steering group will review the proposed indicators, and the agreed quality indicators will be integrated into an on-line Delphi questionnaire. One hundred participants will be invited to form the Delphi consensus panel and will include a wide range of stakeholders, including people accessing OAT services, general practitioners, pharmacists and outreach workers. Evidence generated from this study will inform national policy decisions in relation to improving quality of care in OAT.

Factors affecting addiction severity index (ASI) among clients enrolled in methadone maintenance treatment (MMT) program in Myanmar

BACKGROUND

Opioid substitution with methadone maintenance treatment (MMT) is shown to reduce illicit opioid use and renew social functioning. Understanding factors that undermine clients' social functioning during MMT treatment is vital for improving treatment compliance and quality of life.

METHOD

A total of 210 respondents who were already enrolled in a formal MMT program in Myanmar were recruited from five cities through stratified random sampling for this cross-sectional study. The addiction severity index (ASI) was used to objectively assess respondents social functioning in the last 30 days. Higher ASI scores denote poorer social functioning.

RESULT

Respondents total ASI scores in the respective domains were: employment (47.4%), alcohol (44.4%), drug use (7.2%), legal (49.2%) and social-family relationship (10.7%). Those reported to have never injected drugs in the last 30 days had lower ASI total scores than those who reported injection drug use (p = 0.01). After identifying the differences in ASI total scores, we found there were significant associations in the clients' hepatitis C status, age category, frequency of heroin injection, quality of life score, marital status, current leisure status with family/friend, current history of injection in the last 30 days, income status, satisfaction with current marital status, as well as reported drug and alcohol use (p < 0.05). Stepwise binary logistic regression showed that alcohol and higher frequency of heroin injection were associated with higher ASI scores. Meanwhile, older age, respondents those who had leisure time with family, and satisfied with current marital status had lower ASI scores (p < 0.05).

CONCLUSION

Our results indicate that those enrolled in the MMT program in Myanmar faced many challenges in their daily social functioning. Treatment providers must take heed of these apparent impediment to ensure clients chequered social functioning does not undermine their treatment compliance.

TRIAL REGISTRATION

NA.

Evaluation of functional status among patients undergoing maintenance treatments for opioid use disorders

Background

Methadone and buprenorphine are the most prevalent types of opioid maintenance programs in Andalusia. The main objective is comparing the functional status of patients with pharmacological opioid maintenance treatments according to different socio-demographic characteristic, health and disabilities domains and sexual difficulties.

Methods

A total of 593 patients from the Andalusia community, 329 were undergoing methadone treatment and 264 were undergoing buprenorphine treatment. The patients were interviewed by socio-demographic and opioid-related variables, assessed by functioning, disability and health domains (WHODAS 2.0.) and for sexual problems (PRSexDQ-SALSEX).

Results

We found significant differences in the socio-demographic and the opioid-related variables as the onset of opioid use, being on previous maintenance programs, opioid intravenous use, the length of previous maintenance programs, polydrug use and elevated seroprevalence rates (HCV and HIV) between the methadone group and the buprenorphine group. Regarding health and disability domains there were differences in the Understanding and communication domain, Getting around domain, Participation in society domain and in the WHODAS 2.0. simple and complex score, favoring buprenorphine-treated patients. The methadone group referred elevated sexual impairments compared with the buprenorphine group. Opioid-related variables as seroprevalence rates, other previous lifetime maintenance program, the daily opioid dosage and the daily alcohol use are the most discriminative variables between both groups. Participation in society variables and sexual problems were the most important clinical variables in distinguishing the methadone group from the buprenorphine group regarding their functional status.

Conclusions

The methadone group showed higher prevalence in opioid dependence-related variables, elevated disabilities in participation in society activities and sexual problems compared with the buprenorphine group. This study shows the importance of carry out a functional evaluation in the healthcare follow-up, especially in those areas related with social activity and with sexual problems.

Legal Authority for Emergency Medical Services to Increase Access to Buprenorphine Treatment for Opioid Use Disorder

Treatment with buprenorphine significantly reduces both all-cause and overdose mortality among individuals with opioid use disorder. Offering buprenorphine treatment to individuals who experience a nonfatal opioid overdose represents an opportunity to reduce opioid overdose fatalities. Although some emergency departments (EDs) initiate buprenorphine treatment, many individuals who experience an overdose either refuse transport to the ED or are transported to an ED that does not offer buprenorphine. Emergency medical services (EMS) professionals can help address this treatment gap. In this Concepts article, we describe the federal legal landscape that governs the ability of EMS professionals to administer buprenorphine treatment, and discuss state and local regulatory considerations relevant to this promising and emerging practice.

Incidence and factors associated with discontinuation of opioid agonist therapy among people who inject drugs in Australia

AIMS

To estimate incidence and predictors of opioid agonist therapy (OAT) discontinuation in a national cohort of people who inject drugs (PWID).

DESIGN AND SETTING

Annually repeated cross-sectional serosurveillance among PWID attending ~50 needle-syringe programmes across Australia.

PARTICIPANTS

Between 1995 and 2018, 2651 PWID who reported current OAT and had subsequent survey participation completed 6739 surveys. Respondents were followed over 11 984 person-years of observation (PYO). Respondents were predominantly male (60%), and the median age was 34 years. Heroin was the most commonly reported drug last injected (46%), and methadone was the most commonly prescribed OAT (77%).

MEASUREMENTS

The primary outcome was discontinuation of OAT (methadone, buprenorphine or buprenorphine-naloxone). Among respondents who reported current OAT, those who did not report current OAT in all subsequent records were defined as discontinued, and those with current OAT at all subsequent records were defined as retained. Predictors of discontinuation included self-reported demographic (sex, location, Indigenous status) and drug use characteristics (drug last injected, frequency of injection).

FINDINGS

Just fewer than one-third of respondents (29%) reported an OAT discontinuation event. The crude discontinuation rate was 6.3 [95% confidence intervals (CI) = 5.9-6.8] per 100 PYO. Discontinuation was significantly higher among respondents who reported last injecting pharmaceutical opioids [adjusted hazard ratio (aHR) = 1.75, 95% CI = 1.41-2.17, P < 0.001], being prescribed buprenorphine (aHR = 1.44, 95% CI = 1.18-1.76, P = 0.001) or buprenorphine-naloxone (aHR = 1.68, 95% CI = 1.20-2.34, P = 0.002), daily or more frequent injection (aHR = 1.51, 95% CI = 1.23-1.85, P < 0.001), recent public injecting (aHR = 1.37, 95% CI = 1.17-1.60, P < 0.001), incarceration in the previous 12 months (aHR = 1.31, 95% CI = 1.05-1.64, P = 0.017), recent receptive syringe or injection equipment sharing (aHR = 1.28, 95% CI = 1.10-1.48, P = 0.001) and male sex (aHR = 1.27, 95% CI = 1.09-1.47, P = 0.002).

CONCLUSION

People who inject drugs attending needle-syringe programmes in Australia appear to be significantly more likely to discontinue opioid agonist treatment if they were prescribed buprenorphine or buprenorphine-naloxone compared with methadone, are male or report injection risk behaviours and recent incarceration.

Factors associated with early and later dropout from methadone maintenance treatment in specialist addiction clinics: a six-year cohort study using proportional hazards frailty models for recurrent treatment episodes

BACKGROUND

Retention in methadone maintenance treatment (MMT) is associated with reduced illicit drug use, criminal activity, and mortality; however, many clients move in and out of MMT. This study aims to identify determinants of time to dropout of MMT across multiple treatment episodes in specialist addiction services in Ireland.

METHODS

Cohort study of persons attending specialist addiction clinics between 2010 and 2015. MMT episodes were periods of continuous treatment if there were no interruptions to treatment lasting > 7days. Proportional hazards frailty models were used to assess factors associated with time to dropout from recurrent MMT episodes at 3 (90 days) and 12 months (91-365 days). MMT episodes were right- censored at time of death, transfer to prison or primary care, and study end.

RESULTS

A total of 2,035 individuals experienced 4,969 MMT episodes, with 2,724 dropout events during the six-year follow-up. Factors associated with dropout at 3 months included low dose methadone (<60 mg/day) (HR = 1.49, 95% CI 1.29-1.73) and previous dropout (HR = 1.65, 95% CI 1.41-1.92). Adherence was protective (HR = 0.91, 95% CI 0.90-0.92). Dropout at 12 months was associated with low dose methadone (HR = 1.44, 95% CI 1.23-1.68), previous dropout (HR = 1.37, 95% CI 1.16-1.61), males (HR 1.26, 95% CI 1.06-1.50), benzodiazepines (HR = 1.22, 95% CI 1.03-1.45) and number of comorbidities (HR = 1.12, 95% CI 1.05-1.20); adherence was protective (HR = 0.86, 95% CI 0.84-0.87).

CONCLUSIONS

Clients with a previous history of treatment dropout and those on low dose methadone should be identified as high risk for both early and later dropout. Inversely, adherence to treatment, not missing methadone doses, is protective.

Acquired immune deficiency syndrome (AIDS) and late presentation in Poland - data from Test and Keep in Care (TAK) Polska project

OBJECTIVES

Late presentation (LP) at HIV diagnosis is associated with worse prognosis and an increase in the number of new infections. We analyse the proportion of patients diagnosed late and factors related to LP in Poland in 2016-2017.

METHODS

Data were obtained from 13 out of 17 HIV centres in Poland from 2016 and 2017, including date of diagnosis, age, sex, transmission route, anti-hepatitis C virus (anti-HCV), Venereal Diseases Research Laboratory (VDRL) antibodies, AIDS diagnosis, baseline HIV viral load and CD4 count.

RESULTS

Out of 1522 patients, 88.9% were male with median age of 33.6 years. Men who have sex with men (MSM) comprised 69.4% of all new infections, heterosexual route of transmission (HTX) 18.2% and injecting drug use (IDU) 4.7%. Late presenters comprised 44.8% of the study group. Factors associated with LP were female sex [odds ratio (OR) = 1.5, 95% confidence interval (95% CI): 1.09-2.08], older age (OR = 1.59, 95% CI: 1.42-1.79 per decade), route of transmission (HTX: OR = 1.96, 95% CI: 1.50-2.56; IDU: OR = 3.17, 95% CI: 1.92-5.37), positive HCV results (OR = 1.90, 95% CI: 1.23-2.95) and syphilis diagnosis (OR = 2.06, 95% CI: 2.29-3.31). Adjusting for these factors, the only independent factors associated with LP were age (OR = 1.52, 95% CI: 1.35-1.71) and route of transmission (HTX: OR = 1.73, 95% CI: 1.23-2.44; IDU: OR = 2.24, 95% CI: 1.25-4.10).

CONCLUSIONS

Late presentation in Poland follows European trends. A total of 44.8% of all newly diagnosed patients in Poland continue to present late or at the AIDS stage. Independent factors associated with LP/AIDS were older age, IDU and HTX. Patients from these groups should be targeted to improve early diagnosis and medical care.

The real-world impact of dosing of methadone and buprenorphine in retention on opioid agonist therapies in Ukraine

BACKGROUND AND AIMS

Ukraine's HIV epidemic remains concentrated among opioid-dependent people who inject drugs (PWID) where opioid agonist therapies (OAT) like methadone (MMT) and buprenorphine (BMT) maintenance treatments are the most cost-effective HIV prevention strategies, but remain under-scaled. This study aimed to measure the association between dose and type of OAT prescribed and treatment retention.

DESIGN

Observational longitudinal cohort study.

PARTICIPANTS AND SETTING

Patients (n = 15 290) prescribed OAT throughout Ukraine from 2004 through 2016.

MEASUREMENTS

Data were analyzed using time-event strategies to estimate cumulative treatment retention, defined as time to OAT discontinuation. Cumulative retention proportions at 1, 12 and 36 months were assessed for outcomes. Cox regression with log-rank likelihood assessed independent predictors of treatment discontinuation.

FINDINGS

The proportion prescribed high (MMT: > 85 mg; BMT: ≥ 16 mg), medium (MMT: > 40-85 mg; BMT: > 6-15 mg) and low (MMT: ≤ 40 mg; BMT: ≤ 6 mg) dosages was 25, 43 and 32%, respectively. Retention was significantly higher for BMT than MMT both at 12 (89 versus 75%) and 36 months (80 versus 56%). Although dosing levels for BMT did not influence retention, increasing dosages for MMT were significantly associated with higher retention rates at 1 (90, 96, 99%), 12 (59, 78, 91%) and 36 (34, 59, 79%) months, respectively. Independent predictors associated with 12-month OAT discontinuation were medium [adjusted hazard ratio (aHR) = 2.23; 95% confidence limit (CL) = 1.95-2.54] and low (aHR = 4.96; 95% CL = 4.37-5.63) OAT dosage relative to high dosage, male sex (aHR = 1.27; 95% CL = 1.14-1.41), MMT relative to BMT prescription (aHR = 1.57; 95% CL = 1.32-1.87) and receiving OAT in general (aHR = 1.22; 95% CL = 1.02-1.46) or tuberculosis (aHR = 1.43; 95% CL = 1.10-1.85) hospitals, relative to specialty addiction treatment and AIDS center settings. Lower dosages contributed more to dropout especially at 1 month (aHR 3.12; 95% CL = 2.21-4.41 and aHR 7.71; 95% CL = 5.51-10.79 for medium and low dosages, respectively). Younger age was significantly associated with OAT discontinuation only at 36 months (aHR = 1.08; 95% CI = 1.02-1.15).

CONCLUSIONS

Higher dosages of opioid agonist therapies, especially for methadone maintenance treatment patients, appear to be associated with higher levels of treatment retention in Ukraine.

No Increase in HIV Drug Resistance Mutations among Injecting Drug Users on Methadone Maintenance Therapy: A Prospective Cohort Study

BACKGROUND

Whether HIV-positive injecting drug users (IDUs) are at higher risk of developing drug resistance mutations (DRMs) after methadone maintenance therapy (MMT) than any other HIV-positive population is unclear.

OBJECTIVE

To compare the incidence of new DRMs in two population groups: antiretroviraltreatment (ART) HIV-positive IDUs and non-drug users.

METHODS

A prospective cohort of ART HIV-positive patients including IDUs who received MMT (MMT group) and non-drug users (N-MMT group) was established from April 2016 to December 2017 in Guangxi, China.

RESULTS

Of the 80 participants, 43 were in the MMT group and 37 were in the N-MMT group. Compared with the N-MMT group, the HRs of PIs, NRTIs and NNRTIs for new DRMs in the MMT group was 1.55 (95%CI: 0.28-8.64; P = 0.616), 1.51 (95%CI: 0.44-5.20; P = 0.512) and 0.45 (95%CI: 0.15-1.35; P = 0.155), respectively. There was no dose-response relationship between MMT and new DRMs for PIs, NRTIs and NNRTIs (P > 0.05). The new DRM incidence for NRTIs (138.23 per 104 person-months) was higher than for PIs (94.16 per 104 person-months) and NNRTIs (95.41per 104 person-months) in the MMT group, while the new DRM incidence for NNRTIs (208.24 per 104 person-months) was higher than for PIs (44.13 per 104 person-months) and NRTIs (91.78 per 104 person-months) in the N-MMT group.

CONCLUSION

Among ART HIV-positive patients, there is no significant difference in the incidence of new DRMs between IDUs receiving MMT and non-drug users. MMT has little impact on the development of DRMs among IDUs.

Do interruptions to the continuity of methadone maintenance treatment in specialist addiction settings increase the risk of drug-related poisoning deaths? A retrospective cohort study

AIMS

To examine the risk of mortality associated with interruptions to the continuity of methadone maintenance treatment (MMT), including transfers between services, in opioid-dependent individuals attending specialist addiction services.

DESIGN

Retrospective cohort study using addiction services and primary care dispensing records, the National Methadone Register and National Drug-Related Death Index (NDRDI).

SETTING

Geographically defined population in Dublin, Ireland.

PARTICIPANTS

A total of 2899 people prescribed and dispensed methadone in specialist addiction services between January 2010 and December 2015. There were five exposure groups: weeks 1-4 following transfer between treatment providers; weeks 1-4 out of treatment; weeks 5-52 out of treatment; weeks 1-4 of treatment initiation; and weeks 5+ of continuous treatment (reference category).

MEASUREMENTS

Primary outcome: drug-related poisoning (DRP) deaths. Secondary outcome: all-cause mortality (ACM). Mortality rates calculated by dividing number of deaths (DRP; ACM) in exposure groups by person-years exposure. Unadjusted and adjusted Poisson regression (covariates age, sex, incarceration, methadone dose and comorbidities) estimated differences in mortality rates.

FINDINGS

There were 154 ACM deaths, 55 (35.7%) identified as DRP deaths. No deaths were observed in the first month following transfer between treatment providers. The risk of DRP mortality was highest in weeks 1-4 out of treatment [adjusted relative risk (aRR = 4.04, 95% confidence interval (CI) = 1.43-11.43, P = 0.009] and weeks 1-4 of treatment initiation (ARR = 3.4, 95% CI = 1.2-9.64, P = 0.02). Similarly, risk of ACM was highest in weeks 1-4 out of treatment (ARR = 11.78, 95% CI = 7.73-17.94, P < 0.001), weeks 1-4 of treatment initiation (aRR = 5.11, 95% CI = 2.95-8.83, P < 0.001) and weeks 5-52 off treatment (aRR = 2.04, 95% CI = 1.2-3.47, P = 0.009).

CONCLUSIONS

Interruptions to the continuity of methadone maintenance treatment by treatment provider do not appear to be periods of risk for drug-related poisoning or all-cause mortality deaths. Risk of drug related poisoning and all-cause mortality deaths appears to be greatest during the first 4 weeks of treatment initiation/re-initiation and after treatment cessation.

Perspectives of clients and providers on factors influencing opioid agonist treatment uptake among HIV-positive people who use drugs in Indonesia, Ukraine, and Vietnam: HPTN 074 study

BACKGROUND

Opioid agonist treatment (OAT) is an effective method of addiction treatment and HIV prevention. However, globally, people who inject drugs (PWID) have insufficient OAT uptake. To expand OAT access and uptake, policymakers, program developers and healthcare providers should be aware of barriers to and facilitators of OAT uptake among PWID.

METHODS

As a part of the HPTN 074 study, which assessed the feasibility of an intervention to facilitate HIV treatment and OAT in PWID living with HIV in Indonesia, Ukraine, and Vietnam, we conducted in-depth interviews with 37 HIV-positive PWID and 25 healthcare providers to explore barriers to and facilitators of OAT uptake. All interviews were audio-recorded, transcribed, translated into English, and coded in NVivo for analysis. We developed matrices to identify emergent themes and patterns.

RESULTS

Despite some reported country-specific factors, PWID and healthcare providers at all geographic locations reported similar barriers to OAT initiation, such as complicated procedures to initiate OAT, problematic clinic access, lack of information on OAT, misconceptions about methadone, financial burden, and stigma toward PWID. However, while PWID reported fear of drug interaction (OAT and antiretroviral therapy), providers perceived that PWID prioritized drug use over caring for their health and hence were less motivated to take up ART and OAT. Motivation for a life change and social support were reported to be facilitators.

CONCLUSION

These results highlight a need for support for PWID to initiate and retain in drug treatment. To expand OAT in all three countries, it is necessary to facilitate access and ensure low-threshold, financially affordable OAT programs for PWID, accompanied with supporting interventions. PWID attitudes and beliefs about OAT indicate the need for informational campaigns to counter misinformation and stigma associated with addiction and OAT (especially methadone).

Retention and outcomes for clients attending a methadone clinic in a resource-constrained setting: a mixed methods prospective cohort study in Imphal, Northeast India

Background

Opioid substitution therapy (OST) with buprenorphine has been widely available in India since 2007, but the introduction of methadone occurred much later in 2012, and availability remains limited. Illicit injecting drug use is a long-standing public health problem in Manipur, a state in Northeast India characterised by major resource constraints and political unrest. We investigated retention and outcomes for clients attending a methadone-based OST program in Manipur with the aim of strengthening the evidence base for development of relevant policies and programs.

Methods

All clients enrolling in the methadone clinic over a 1 year period were invited to be part of a prospective cohort study, which followed up and surveyed both retained and defaulting clients for 12 months post-enrollment to assess retention as well as social, behavioural and mental health outcomes. Additionally, we conducted semi-structured qualitative interviews to supplement quantitative information and identify factors contributing to retention and drop-out.

Results

Of the 74 clients enrolled, 21 had dropped out and three had died (all defaulters) by 12 months post-enrollment, leaving 67.6% still in the program. Using an intention-to-treat analysis, meaningful and statistically significant gains were observed for all social, behavioural and mental health variables. Between baseline and 12 months there were reductions in needle sharing, drug use, property crime, anxiety, depression and suicidal thoughts; and improvements in physical health, mental health, quality of family relationships, employment and hopefulness. Factors contributing to retention and drop-out were identified, including the centrality of family, and general lack of awareness of and misunderstanding about methadone.

Conclusion

Even in parts of India where resources are constrained, methadone is an effective treatment for opioid dependence. Scaling up the availability of methadone elsewhere in Manipur and in other areas of India experiencing problematic opioid dependence is indicated.

Epidemiology of HIV in Iran

:

Iran has been one of the active countries fighting against HIV/AIDS in the Middle East during the last decades. Moreover, there is a strong push to strengthen the national health management system concerning HIV prevention and control. In Iran, HIV disease has its unique features, from changes in modes of transmission to improvement in treatment and care programs, which can make it a good case for closer scrutiny. The present review describes the HIV epidemic in Iran from the first case diagnosed until prevention among different groups at risk and co-infections. Not only we addressed the key populations and community-based attempts to overcome HIV-related issues in clinics, but we also elaborated on the efforts and trends in society and the actual behaviors related to HIV/AIDS. Being located in the Middle East and North Africa (MENA) region, given the countryspecific characteristics, and despite all the national efforts along with other countries in this region, Iran still needs to take extra measures to reduce HIV transmission, especially in health education. Although Iran is one of the pioneers in implementing applicable and appropriate policies in the MENA region, including harm reduction services to reduce HIV incidence, people with substance use disorder continue to be the majority of those living with HIV in the country. Similar to other countries in this region, the HIV prevention and control programs aim at 90-90-90 targets to eliminate HIV infection and reduce the transmission, especially the mother-to-child transmission and among other key populations.

Barriers to healthcare delivery in Iranian prisons: a qualitative study

PURPOSE

High quality health-care delivery is not only the governments' responsibility but also every prisoner's right. Health care in prison and, particularly, of Iranian prisoners is increasingly important topic because of the rising number of the prison population. This paper aims to explore health-care managers' perspectives and experiences of prisons and the barriers to health-care delivery in Iranian prisons.

DESIGN/METHODOLOGY/APPROACH

A qualitative research design was conducted in Iran from October 2018 to August 2019. The participants consisted of 51 health-care managers (50 men and one woman) from Iranian prisons. A combination of face-to-face (N = 42) and telephonic (N = 9) semi-structured interviews were used because of the geographical distribution of the respondents. The first part of the interview guide consisted of demographic characteristics, and the second part consisted of three main open ended-questions. Interviews were recorded and transcribed, and thematic descriptive analysis was used to interpret the data.

FINDINGS

The barriers to health-care delivery in Iranian prisons were categorized into four main topics: human resources, financing, facilities and barriers related to the health-care delivery process. Data synthesis identified the following themes for barriers to human resources: barriers to human resources planning (with eight sub-themes); barriers to education (with three sub-themes); and motivational barriers (with seven sub-themes). Moreover, barriers to financing consisted of five sub-themes. The barriers to facilities consisted of barriers related to physical infrastructures (with two sub-themes) and barriers related to equipment (with six sub-themes). Finally, barriers to the health-care delivery process included the following themes: communication barriers (with six sub-themes); legal barriers (with five sub-themes); and environmental-demographic factors (with seven sub-themes).

ORIGINALITY/VALUE

Identifying the barriers to health-care delivery in Iranian prisons plays a critical role in the improvement of planning, decision-making and the health-care delivery process.

The evolution of addiction treatment and harm reduction programs in Iran: a chaotic response or a synergistic diversity?

BACKGROUNDS AND AIMS

Iran has 2.1 and 1.8% of its 15-64-year-old population living with illicit substance and opioid use disorders, respectively. To address these problems, Iran has been developing a large and multi-modality addiction treatment system, spanning the time before and after the Islamic Revolution.

METHODS

Iran's current drug treatment scene is a combination of services, ranging from medical/harm reduction services to punitive/criminal justice programs. Included in this array of services are drop-in centers providing low-threshold harm reduction services, such as distribution of sterile needles and syringes; opioid maintenance treatment clinics providing methadone, buprenorphine and opium tincture; and abstinence-based residential centers. We will review the evolution of this system in four phases.

RESULTS

In 1980, Iran's revolutionary government shut down all voluntary treatment programs and replaced them with residential correctional programs. The first shift in the addiction treatment policies came 15 years later after facing the negative consequences. Addiction is viewed as a disease, and new voluntary treatment centers offering non-agonist medications and psychosocial services were established. With an increased number of people who inject drugs and HIV/AIDS epidemics, in the second shift an extensive move towards harm reduction strategies and opioid-maintenance programs has been implemented to reduce HIV-related high-risk behavior. The emergence of a methamphetamine use crisis creating an increased number of socially marginalized addicted people resulted in public and political demands for stricter policies and ended in the third shift starting in 2010, with extended compulsory court-based residential programs. Currently, there is a new shift towards reducing the severity of criminal penalties for drug use/sales and promoting proposals for opium legalization.

CONCLUSION

Iran's evolutionary experience in developing a large addiction treatment program in a complex combination of medical/harm reduction and punitive/criminal justice addiction treatment can be examined in its political, clinical and pragmatic context.

Retention of patients in opioid substitution treatment: A systematic review

Background

Retention in opioid substitution (OST) treatment is associated with substantial reductions in all cause and overdose mortality. This systematic review aims to identify both protective factors supporting retention in OST, and risk factors for treatment dropout.

Methods

A systematic search was performed using MEDLINE, Embase, PsycInfo, CINAHL and Web of Science (January 2001 to October 2019). Randomised controlled trials (RCTs) and observational cohort studies reporting on retention rates and factors associated with retention in OST were included. Factors associated with treatment retention and dropout were explored according to the Maudsley Addiction Profile. A narrative synthesis is provided.

Results

67 studies were included in this review (4 RCTs and 63 observational cohort studies; N = 294,592), all assessing factors associated with retention in OST or treatment dropout. The median retention rate across observational studies was approximately 57% at 12 months, which fell to 38.4% at three years. Studies included were heterogeneous in nature with respect to treatment setting, type of OST, risk factor assessment, ascertainment of outcome and duration of follow-up. While the presence of such methodological heterogeneity makes it difficult to synthesise results, there is limited evidence to support the influence of a number of factors on retention, including age, substance use, OST drug dose, legal issues, and attitudes to OST.

Conclusions

Younger age, substance use particularly cocaine and heroin use, lower doses of methadone, criminal activity/incarceration, and negative attitudes to MMT appear to be associated with reduced retention in OST. A consensus definition of retention is required to allow for comparability across future studies.

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

BACKGROUND

Moral conservatism within government and communities has resulted in a reluctance to support the provision of opioid agonist therapy for people with opioid use disorders in South Africa. In April 2017, South Africa's first low-threshold opioid agonist therapy demonstration project was launched in Durban. The project provided 54 low-income people with heroin use disorders methadone and voluntary access to psychosocial services for 18 months. At 12 months, retention was 74%, notably higher than the global average. In this paper, we aim to make sense of this outcome.

METHODS

Thirty semi-structured interviews, two focus groups, ten oral histories and ethnographic observations were done at various project time points. These activities explored participants' pathways into drug use and the project, their meaning attributed to methadone, the factors contributing to project success and changes they experienced. Recordings, transcripts, notes and feedback were reviewed and triangulated. Key factors contributing to retention were identified and analysed in light of the existing literature.

RESULTS

The philosophy and architecture of the project, and social cohesion were identified as the main factors contributing to retention. The use of a harm reduction approach enabled participants to set and be supported to achieve their treatment goals, and was shown to be important for the development of trusting therapeutic relationships. The employment of a restorative justice paradigm provided a sense of acceptance of humanity and flaws as well as an imperative to act responsibly towards others, fostering a culture of respect. Social cohesion was fostered through the facilitation of group sessions, a peace committee and group sport (soccer). In concert, these activities provided opportunities for participants to demonstrate care and interest in one another's life, leading to interdependence and care, contributing to them remaining in the project.

CONCLUSIONS

We believe that the high retention was achieved through attraction. We argue that opioid agonist therapy programmes should take the principles of harm reduction and restorative justice into consideration when designing low-threshold opioid agonist therapy services. Additionally, ways to support cohesion amongst people receiving agonist therapy should be explored to support their effective scale-up, both in low-middle income countries and in high-income countries.

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

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

HIV prevalence among people who inject drugs (PWID) and related factors in Iran: a systematic review, meta-analysis and trend analysis

AIMS

In Iran, injecting drug use has been the major route of human immunodeficiency virus (HIV) transmission. In order to control the HIV epidemic, a harm reduction program was initiated and has been expanded in recent years. The aim of this study was to provide an updated estimate of HIV prevalence among people who inject drugs (PWID) in Iran, investigate prevalence differences over time and assess prevalence correlates.

DESIGN

A comprehensive systematic review was undertaken in the international, regional and national bibliographic databases in November 2018 and extensive contacts with authors were made. For studies conducted before 2005, we used data from a previous published systematic review.

SETTING

All studies conducted in Iran were included. Recruitment settings included anywhere except studies conducted in infectious diseases wards or HIV counseling centers.

PARTICIPANTS

PWID with any definition utilized in the studies. Thirty-six studies were included, which were conducted in 24 of 31 provinces with a sample size of 22 160 PWID.

MEASUREMENTS

We included studies that had performed HIV testing and had a confirmed diagnosis of HIV through repeating the enzyme-linked immunosorbent assay (ELISA) or Western immunoblot assay (WB). Pooled prevalence of HIV was calculated for the total sample and for different subgroups, by available socio-demographic and behavioral factors. For assessing the trend of HIV prevalence over time, a linear meta-regression model was fitted separately for before 2007 and during 2007 and afterwards.

FINDINGS

The pooled prevalences of HIV before 2007 and in 2007 and afterwards were 14.3% [95% confidence interval (CI) = 9.8-18.9] and 9.7% (95% CI = 7.6-11.9), respectively. HIV prevalence increased until 2005-06 and then slowly declined until 2009-10, which was not significant. Prevalence of HIV was significantly higher in PWID above age 25 years, and in those with history of imprisonment and history of needle/syringe-sharing. HIV prevalence was higher in men than in women, but the difference was insignificant.

CONCLUSION

The prevalence of HIV among people who inject drugs in Iran decreased after 2006 which could, at least in part, be attributed to the development of extensive harm reduction programs in the country.

Modeling the role of incarceration in HCV transmission and prevention amongst people who inject drugs in rural Kentucky

BACKGROUND

People who inject drugs (PWID) experience high incarceration rates, with current/recent incarceration being associated with increased hepatitis C virus (HCV) transmission. We assess the contribution of incarceration to HCV transmission amongst PWID in Perry County (PC), Kentucky, USA, and the impact of scaling-up community and in-prison opioid substitution therapy (OST), including the potential for reducing incarceration.

METHODS

A dynamic model of incarceration and HCV transmission amongst PWID was calibrated in a Bayesian framework to epidemiological and incarceration data from PC, incorporating an empirically estimated 2.8-fold (95%CI: 1.36-5.77) elevated HCV acquisition risk amongst currently incarcerated or recently released (<6 months) PWID compared to other PWID. We projected the percentage of new HCV infections that would be prevented among PWID over 2020-2030 if incarceration no longer elevated HCV transmission risk, if needle and syringe programmes (NSP) and OST are scaled-up, and/or if drug use was decriminalized (incarceration/reincarceration rates are halved) with 50% of PWID that would have been imprisoned being diverted onto OST. We assume OST reduces reincarceration by 10-42%.

RESULTS

Over 2020-2030, removing the effect of incarceration on HCV transmission could prevent 42.7% (95% credibility interval: 15.0-67.4%) of new HCV infections amongst PWID. Conversely, scaling-up community OST and NSP to 50% coverage could prevent 28.5% (20.0-37.4%) of new infections, with this increasing to 32.7% (24.5-41.2%) if PWID are retained on OST upon incarceration, 36.4% (27.7-44.9%) if PWID initiate OST in prison, and 45.3% (35.9-54.1%) if PWID are retained on OST upon release. decriminalization (with diversion to OST) could further increase this impact, preventing 56.8% (45.3-64.5%) of new infections. The impact of these OST interventions decreases by 2.1-28.6% if OST does not reduce incarceration.

CONCLUSION

Incarceration is likely to be an important contributor to HCV transmission amongst PWID in PC. Prison-based OST could be an important intervention for reducing this risk.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

An Inverse Relationship Between Alcohol and Heroin Use in Heroin Users Post Detoxification

Background

Given that fewer than 50% of countries provide Opioid Agonist Maintenance Therapies (OAMT), it is important to assess whether other substances act as a substitute for heroin in recovering heroin users who receive detoxification models of treatment. There is a dearth of prospective studies from low-and-middle-income countries evaluating these patterns of substance use.

Methods

300 heroin users from the Gauteng province of South Africa were assessed on entry into inpatient detoxification and then followed-up 3 and 9 months after leaving treatment. Treatment consisted of 1 week of detoxification followed by 6-8 weeks of psychosocial therapy. We measured the overall changes in the prevalence of heroin, alcohol and other drug use at baseline and postrehabilitation. Comparison of these outcomes at enrolment, 3 months and 9 months was performed by a Generalised Estimating Equation (GEE) with the outcome as the dependent variable, observation point as the independent variable, and participant as the repeated measure. Injecting status and treatment completion were included as covariates. We also measured the individual pathways between heroin and alcohol use in the 210 participants that were seen at all three timepoints.

Results

Of the original cohort, 252 (84.0%) were re-interviewed at 3 months and 225 (75.0%) at 9 months. From baseline to 3 months, the proportion of past month heroin users decreased significantly to 65.5%; however, during this time, the proportion of past month alcohol users increased from 16.3% to 55.2% (p<0.0001). When assessing the pathways between heroin and alcohol use at an individual level, 55.4% (n-97) of those who were past month alcohol abstinent prior to rehabilitation were using alcohol at 3 months. From 3 to 9 months the proportion of heroin users increased to 72.4% (p<0.0001), and during this time, the proportion of alcohol users decreased.

Conclusion

After detoxification, a significant reduction in heroin use was observed with a concomitant increase in alcohol consumption. Under these circumstances, alcohol may have acted as a substitute for heroin in the short term. The initial reduction in heroin use 3 months postrehabilitation was followed by increased consumption 6 months later. This observation supports the need for interventions to prevent, monitor and treat high levels of alcohol use in heroin users post detoxification. The provision of OAMT is a necessary consideration to address both the risk of increased alcohol intake as well as the decline in heroin abstinence rates.

Receipt of opioid agonist treatment halves the risk of HIV-1 RNA viral load rebound through improved ART adherence for HIV-infected women who use illicit drugs

BACKGROUND

Women living with HIV who use illicit drugs may be particularly vulnerable to HIV-1 RNA viral load (VL) rebound.

METHODS

We used longitudinal data from 2006 to 2017 to evaluate the impact of sociodemographic, behavioral, social-structural, and clinical factors on the hazard of viral rebound for women enrolled in the ACCESS study, a prospective cohort with systematic VL monitoring. Women were included if they achieved VL suppression (<50 copies/mL) following antiretroviral therapy (ART) initiation and had more than one study interview. Sociodemographic as well as substance use, social-structural, addiction treatment, and HIV clinical factors were evaluated as predictors of viral rebound (VL > 1000 copies/mL). Cox regressions using a recurrent events framework, time-varying covariates, robust standard errors, and a frailty component were used.

RESULTS

Of the 185 women included, 62 (34%) experienced at least one viral rebound event over an 11-year period, accumulating a total of 87 viral rebound events. In adjusted analysis, stimulant use more than doubled the hazard of viral rebound (adjusted hazard ratio [AHR]: 2.35, 95% confidence interval [CI]: 1.07-5.14) while the only factor protective against viral rebound was receipt of opioid agonist treatment (OAT) in the past six months (AHR: 0.46, 95% CI: 0.26-0.81). After adjusting for ART adherence in the past six months, the effect of OAT was attenuated (AHR: 0.57, 95% CI: 0.32-1.02).

CONCLUSIONS

Efforts to improve access to and retention within OAT programs and decrease stimulant use may improve rates of viral suppression for HIV-positive women who use illicit drugs.

Prevalence of Opioid Dependence and Opioid Agonist Treatment in the Berlin Custodial Setting: A Cross-Sectional Study

BACKGROUND

Among people living in detention, substance use is highly prevalent, including opioid dependence. Opioid agonist treatment (OAT) has been established as an evidence-based, first-line treatment for opioid dependence. Despite high prevalence of opioid dependence, conclusive data regarding its prevalence and the OAT practice in German prisons is scarce; rather, the existing data widely diverges concerning the rates of people in detention receiving OAT.

MATERIALS AND METHODS

We conducted a cross-sectional survey of all detention facilities in Berlin. On the date of data collection, a full census of the routine records was completed based on the medical documentation system. For each opioid dependent individual, we extracted sociodemographic data (i.e., age, sex, and non-/German nationality, whether people experienced language-related communication barriers), information about OAT, comorbidities (HIV, hepatitis C, schizophrenia), and the detention center, as well as the anticipated imprisonment duration and sentence type. The data was first analyzed descriptively and secondly in an evaluative-analytical manner by analyzing factors that influence the access to OAT of people living in detention.

RESULTS

Among the 4,038 people in detention in the Berlin custodial setting under investigation, we identified a 16% prevalence of opioid dependence. Of the opioid-dependent individuals, 42% received OAT; 31% were treated with methadone, 55% were treated with levomethadone, and 14% were treated with buprenorphine. Access to OAT seemed mainly dependent upon initial receipt of OAT at the time of imprisonment, detention duration, the prisons in which individuals were detained, German nationality, and sex. The overall prevalence of HIV was 4-8%, hepatitis C was 31-42%, and schizophrenia was 5%.

CONCLUSIONS

The prevalence of opioid dependence and access to OAT remains a major health issue in the custodial setting. OAT implementation must be especially intensified among male, non-German, opioid-dependent individuals with a short detention period. Treatment itself must be diversified regarding the substances used for OAT, and institutional treatment differences suggest the need for a consistent treatment approach and the standardized implementation of treatment guidelines within local prison's standard operating procedures. Testing for infectious diseases should be intensified among opioid-dependent people living in detention to address scarcely known infection statuses and high infection rates.

Sexual dysfunction in men on buprenorphine - naloxone-based substitution therapy

BACKGROUND

The literature on sexual dysfunction in patients on buprenorphine-naloxone (BNX) substitution is limited.

MATERIALS AND METHODS

This research aimed to study the prevalence and correlates of sexual dysfunction in men on BNX substitution therapy. We recruited consecutive forty men from BNX clinic, who had received BNX for at least 6 months, who were free from any recent illicit drug use (confirmed by urine chromatographic immune assay), and who were either married or had a stable sexual partner. Men with other psychiatric and substance use disorders (except tobacco) were excluded from the study. Data for the control group were obtained from a published study (with similar selection criteria) from our center. We assessed sexual dysfunction with two cross-culturally validated instruments: Arizona Sexual Experience Scale (ASEX) and International Index of Erectile Function.

RESULTS

The sample had a mean age of 31.6 (±8) years; the mean duration of BNX treatment was 9 (±4.2) months and the mean BNX dose was 4.5 (±1.6) mg. ASEX showed the prevalence of sexual dysfunction to be 40%. The IIEF demonstrated intercourse dissatisfaction (95%) and hypoactive sexual desire (92.5%) as almost universal, while 77.5% of the participants reported erectile dysfunction. In comparison to the published data, these figures were significantly more than among the controls. We found no correlation of sexual dysfunction with marital status, age, duration or dose of BNX, duration of illicit opioid use, the severity of opioid dependence, and tobacco dependence.

CONCLUSION

All men on BNX maintenance therapy must be screened for sexual dysfunction. With the rapid scaling up of office-based BNX substitution, assessment and management of sexual dysfunction ought to be incorporated in the training curriculum.

Cost-effectiveness of scaling-up HCV prevention and treatment in the United States for people who inject drugs

AIMS

To examine the cost-effectiveness of hepatitis C virus (HCV) treatment of people who inject drugs (PWID), combined with medication-assisted treatment (MAT) and syringe-service programs (SSP), to tackle the increasing HCV epidemic in the United States.

DESIGN

HCV transmission and disease progression models with cost-effectiveness analysis using a health-care perspective.

SETTING

Rural Perry County, KY (PC) and urban San Francisco, CA (SF), USA. Compared with PC, SF has a greater proportion of PWID with access to MAT or SSP. HCV treatment of PWID is negligible in both settings.

PARTICIPANTS

PWID data were collected between 1998 and 2015 from Social Networks Among Appalachian People, U Find Out, Urban Health Study and National HIV Behavioral Surveillance System studies.

INTERVENTIONS AND COMPARATOR

Three intervention scenarios modeled: baseline-existing SSP and MAT coverage with HCV screening and treatment with direct-acting antiviral for ex-injectors only as per standard of care; intervention 1-scale-up of SSP and MAT without changes to treatment; and intervention 2-scale-up as intervention 1 combined with HCV screening and treatment for current PWID.

MEASUREMENTS

Incremental cost-effectiveness ratios (ICERs) and uncertainty using cost-effectiveness acceptability curves. Benefits were measured in quality-adjusted life-years (QALYs).

FINDINGS

For both settings, intervention 2 is preferred to intervention 1 and the appropriate comparator for intervention 2 is the baseline scenario. Relative to baseline, for PC intervention 2 averts 1852 more HCV infections, increases QALYS by 3095, costs $21.6 million more and has an ICER of $6975/QALY. For SF, intervention 2 averts 36 473 more HCV infections, increases QALYs by 7893, costs $872 million more and has an ICER of $11 044/QALY. The cost-effectiveness of intervention 2 was robust to several sensitivity analysis.

CONCLUSIONS

Hepatitis C screening and treatment for people who inject drugs, combined with medication-assisted treatment and syringe-service programs, is a cost-effective strategy for reducing hepatitis C burden in the United States.

Changes in Reported Injection Behaviors Following the Public Health Response to an HIV Outbreak Among People Who Inject Drugs: Indiana, 2016

A syringe services program (SSP) was established following the Indiana HIV outbreak among persons who inject drugs (PWID) in Scott County. Among Indiana-based PWID, we examined injection behaviors associated with HIV status, SSP use after its establishment, and changes in injection behaviors after the outbreak response. During 2016, we interviewed 200 PWID and assessed injection behaviors before the response by HIV status. We reported injection behaviors prior to the response and used Fisher's exact Chi square tests (P < 0.05) to assess differences by HIV status. Next, among persons who injected both before (July-December 2014) and after (past 30 days) the response, we (1) reported the proportion of persons who used the SSP to obtain sterile syringes, and assessed differences in SSP use by HIV status using Fisher's exact Chi square tests; and (2) compared distributive and receptive sharing of injection equipment and disposal of syringes before and after the outbreak response, and assessed statistical differences using McNemar's test. We also compared injection behaviors before and after the response by HIV status. Injecting extended release oxymorphone (Opana® ER); receptive sharing of syringes and cookers; and distributive sharing of cookers, filters, or water before the response were associated with HIV infection. SSP use was high (86%), particularly among HIV-positive compared with HIV-negative persons (98% vs. 84%). Injection equipment sharing decreased and safe disposal of used syringes increased after the response, especially among HIV-positive persons. Injection equipment sharing contributed to the outbreak. High SSP use following the response, particularly among HIV-positive persons, contributed to decreased high-risk injection practices.