1
|
Devlin AM, Wight D. Mechanisms and context in the San Patrignano drug recovery community, Italy: a qualitative study to inform transfer to Scotland. DRUGS (ABINGDON, ENGLAND) 2021; 28:85-96. [PMID: 34824492 PMCID: PMC7612027 DOI: 10.1080/09687637.2020.1747397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The San Patrignano drug recovery community, Italy, is regarded as one of the most successful in the world. However, if this model is to be transferred to other countries, it is necessary to clarify its underlying mechanisms and how far their success is context dependent. This qualitative study investigated these features of the San Patrignano model. Data collection included semi-structured interviews with six key stakeholders and 10 days’ observational field notes. Data were synthesised using frameworks and analysis was informed by realist principles. Individual level mechanisms include: commitment to change, removal from former social environment, communal living, peer mentor with lived experience and meaningful work. These operate in the context of a free of charge, long term (3–4 year) residential community. Organisational level mechanisms are: visionary leadership, staff dedication, social enterprise and adaptable learning. Organisational contextual factors include: a gap in suitable provision for drug recovery and the region’s high level of social capital. Articulating the programme theory of the recovery model and its contextual dependency helps clarify which elements should be transferred and how far they need to be adapted for different socio-cultural settings. The recognition of context is crucial when considering transfer of effective complex interventions across countries.
Collapse
Affiliation(s)
- Alison M Devlin
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Scotland, UK
| | - Daniel Wight
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Scotland, UK
| |
Collapse
|
2
|
Lin L, Lu C, Chen W, Li C, Guo VY. Parity and the risks of adverse birth outcomes: a retrospective study among Chinese. BMC Pregnancy Childbirth 2021; 21:257. [PMID: 33771125 PMCID: PMC8004392 DOI: 10.1186/s12884-021-03718-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/01/2021] [Indexed: 11/30/2022] Open
Abstract
Background Nulliparity is considered to be a risk factor of preterm birth (PTB), low birth weight (LBW) and small for gestational age (SGA). With the new two-child policy launched in 2016, more Chinese women have delivered their 2nd baby. Yet few studies have assessed the impact of parity on adverse birth outcomes in China. This study aimed to examine the association between parity and risks of PTB, LBW and SGA in a Chinese population. The combined effects of maternal age and parity on adverse birth outcomes were also assessed. Methods This retrospective study included all non-malformed live births born during January 1, 2014 and December 31, 2018 in Chengdu, China. A total of 746,410 eligible live singletons with complete information were included in the analysis. Parity was classified into nulliparity (i.e. has never delivered a newborn before) and multiparity (i.e. has delivered at least one newborn before). Log-binomial regression analyses were applied to evaluate the association between parity and PTB, LBW and SGA. We further divided maternal age into different groups (< 25 years, 25–29 years, 30–34 years and ≥ 35 years) to assess the combined effects of maternal age and parity on adverse birth outcomes. Results Multiparity was associated with reduced risks of PTB (aRR = 0.91, 95% CI: 0.89–0.93), LBW (aRR = 0.74, 95% CI: 0.72–0.77) and SGA (aRR = 0.67, 95% CI: 0.66–0.69) compared with nulliparity. In each age group, we observed that multiparity was associated with lower risks of adverse birth outcomes. Compared to nulliparous women aged between 25 and 29 years, women aged ≥35 years had greater risks of PTB and LBW, regardless of their parity status. In contrast, multiparous women aged ≥35 years (aRR = 0.73, 95% CI: 0.70–0.77) and those aged < 25 years (aRR = 0.88, 95% CI: 0.84–0.93) were at lower risk of SGA compared with nulliparous women aged between 25 and 29 years. Conclusion Multiparity was associated with lower risks of all adverse birth outcomes. Special attention should be paid to nulliparous mothers and those with advanced age during antenatal care, in order to reduce the risks of adverse birth outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03718-4.
Collapse
Affiliation(s)
- Li Lin
- Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, Guangdong, China
| | - Ciyong Lu
- Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, Guangdong, China
| | - Weiqing Chen
- Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, Guangdong, China
| | - Chunrong Li
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, Sichuan, China.
| | - Vivian Yawei Guo
- Department of Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, Guangdong, China.
| |
Collapse
|
3
|
Herlinger K, Lingford-Hughes A. Addressing unmet needs in opiate dependence: supporting detoxification and advances in relapse prevention. BJPSYCH ADVANCES 2021. [DOI: 10.1192/bja.2020.98] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
SUMMARY
Despite record-breaking numbers of opiate related deaths in the UK in 2019, pharmacological management of opiate dependence has evolved little since the advent of methadone in 1965. Along with harm minimisation and psychosocial interventions, the mainstay of pharmacological treatment remains opioid substitution therapy (OST) using methadone or buprenorphine, with many patients receiving OST for many years. Even with these treatments, opiate users continue to face mortality risks 12 times higher than the general population, and emerging evidence suggests that individuals who remain on long-term OST present with a range of physical and cognitive impairments. Therefore, with a growing ageing opiate dependent population who would benefit from detoxification from OST, this article provides an overview of the current state of opiate dependence in clinical practice, explores the reasons why availability and acceptability of detoxification pathways are declining, and discusses emerging pharmacological therapies that could provide benefit in relapse prevention.
Collapse
|
4
|
Grebely J, Cerdá M, Rhodes T. COVID-19 and the health of people who use drugs: What is and what could be? THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 83:102958. [PMID: 33183679 PMCID: PMC7837052 DOI: 10.1016/j.drugpo.2020.102958] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
SARS-CoV-2, the virus that causes COVID-19, has changed the world as we know it, and continues to do so. How COVID-19 affects people who use drugs, the environments in which they live, and capacities of response, warrants immediate attention. This special issue begins to map how COVID-19 is altering the health of people who use drugs, including in relation to patterns of drug use, service responses, harms that may relate to drug use, interventions to reduce risk of harms, COVID-19 health, and drug policies. We emphasise the need to envisage COVID-19 and its effects as a matter of intersecting ‘complex adaptive systems’: that is, the impacts of COVID-19 extend beyond the virus and related illness conditions to encompass multiple social, cultural, economic, policy and political effects; and these affect the health of people who use drugs directly as well as indirectly by altering the risk and enabling environments in which they live. We synthesize emergent evidence on the impact of COVID-19 on the health of people who use drugs. A key concern we identify is how to sustain policy and service delivery improvements prompted by COVID-19. We need to maintain an ethos of emergent adaptation and experimentation towards the creation of safer environments in relation to the health of people who use drugs.
Collapse
Affiliation(s)
- Jason Grebely
- The Kirby Institute, UNSW Sydney, Sydney, Australia.
| | - Magdalena Cerdá
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, United States
| | - Tim Rhodes
- Centre for Social Research in Health, UNSW Sydney, Sydney, Australia; London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
5
|
Durand L, O'Driscoll D, Boland F, Keenan E, Ryan BK, Barry J, Bennett K, Fahey T, Cousins G. 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. Addiction 2020; 115:1867-1877. [PMID: 32034837 PMCID: PMC7540578 DOI: 10.1111/add.15004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/02/2019] [Accepted: 02/05/2020] [Indexed: 12/01/2022]
Abstract
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.
Collapse
Affiliation(s)
- Louise Durand
- School of Pharmacy and Biomolecular SciencesRoyal College of Surgeons in IrelandDublinIreland
| | | | - Fiona Boland
- HRB Centre for Primary Care ResearchRoyal College of Surgeons in IrelandDublinIreland
| | - Eamon Keenan
- HSE National Social Inclusion Office, Stewarts HospitalDublinIreland
| | - Benedict K. Ryan
- School of Pharmacy and Biomolecular SciencesRoyal College of Surgeons in IrelandDublinIreland
| | - Joseph Barry
- Department of Public Health and Primary CareTrinity College DublinIreland
| | - Kathleen Bennett
- Division of Population Health SciencesRoyal College of Surgeons in IrelandDublinIreland
| | - Tom Fahey
- Department of General Practice and HRB Centre for Primary Care ResearchRoyal College of Surgeons in IrelandDublinIreland
| | - Gráinne Cousins
- School of Pharmacy and Biomolecular SciencesRoyal College of Surgeons in IrelandDublinIreland
| |
Collapse
|
6
|
Baseline Factors Associated with Mortality in Patients Who Engaged in Buprenorphine Treatment for Opioid Use Disorder: a Cohort Study. J Gen Intern Med 2020; 35:2375-2382. [PMID: 32206993 PMCID: PMC7403281 DOI: 10.1007/s11606-020-05779-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 03/06/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Opioid agonist therapy (OAT) has been shown to reduce mortality in patients with opioid use disorder (OUD), yet mortality in individuals receiving OAT remains higher than in an age- and gender-matched population. OBJECTIVE To identify baseline risk factors in patients who engaged in buprenorphine treatment that are associated with this elevated risk of death. DESIGN We performed a retrospective cohort study from January 1, 2007, to December 31, 2018, using a centralized clinical data registry within a multi-hospital health system in Boston, MA, USA. PARTICIPANTS All adult patients who had ≥ 2 consecutive encounters with sublingual buprenorphine on the active medication list from January 1, 2007, to December 31, 2018. MAIN MEASURES We abstracted several sociodemographic, clinical, and healthcare use characteristics from the clinical data registry. The primary outcome was all-cause mortality and the secondary outcome was opioid overdose-related mortality. We performed multivariable cox regression to identify baseline characteristics independently associated with these outcomes. KEY RESULTS Of 5948 patients in the cohort, the majority were white (80.7%) and male (59.7%), with a mean age of 38.2 years. The all-cause mortality rate was 24.0 deaths per 1000 person-years. Baseline characteristics independently associated with an increased hazard of all-cause mortality included homelessness (adjusted hazard ratio [aHR] = 1.39; 95% confidence interval [CI] = 1.09, 1.78), an opioid on the active medication list (aHR = 1.28; 95% CI = 1.08, 1.52), and entry into the cohort during an inpatient hospitalization (aHR = 1.43; 95% CI = 1.18, 1.73). Homelessness was also associated with an increased hazard of opioid overdose-related mortality (aHR = 1.77; 95% CI = 1.25, 2.50). CONCLUSIONS We identified several novel and potentially modifiable predictors of mortality among patients engaging in buprenorphine treatment who remain at an increased risk of death compared with the general population. Understanding these risk factors can assist healthcare providers in risk stratification and inform the design of targeted interventions to improve outcomes in a high-risk patient population.
Collapse
|
7
|
Gimelfarb Y, Shamir EZ, Ness Dabush K, Ben Tzarfati M. Methadone maintenance treatment and survival of schizophrenic patients with a lifetime comorbid substance use disorders: a long-term follow-up study. J Addict Dis 2020; 38:458-464. [PMID: 32608328 DOI: 10.1080/10550887.2020.1782558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background Methadone maintenance treatment (MMT) remains the most widely used effective therapeutic approach for opioid use disorders. However, there is paucity of empirical data regarding the relationship between the MMT and survival of subjects with schizophrenia. Aim The aim of this study was to examine the effect of MMT on the long-term survival of subjects with schizophrenia and a lifetime comorbid substance use disorders. Methods The charts of 277 consecutive subjects admitted in our center during a period from January 1, 2002 to February 1, 2007 were assessed. Psychiatric diagnoses have been established according to international classification of diseases and health related problems-10th edition (ICD-10). The risk of all-cause mortality was assessed by Cox proportional-hazards regression models, including time-dependent covariates. Results Out of MMT subjects, 31 (11.2%) had mental and behavioral disorders due to multiple psychoactive substance use, 5 (1.8%) had mental and behavioral disorders due to use of opioids. All of 13 (4.7%) subjects with opioid use disorders were treated. MMT has been found to be predictive of lower long-term survival, in time-independent (hazard ration [HR] = 1.88; 95%CI: 1.06-3.37; p<.05) and in time-dependent adjusted models (HR = 2.01; 95%CI: 1.21-3.60; p<.05). MMT daily dose of <120 mg (adjusted HR = 1.83; 95%CI: .95-3.54) and MMT daily dose of ≥120 mg (adjusted HR = 2.70; 95%CI: .97-7.54) were associated with less long-term survival, all compared with no lifetime MMT (p<.046). Conclusions Among subjects with schizophrenia and a lifetime comorbid substance use disorders, overall mortality was higher in those who received lifetime MMT, then in patients without MMT.
Collapse
Affiliation(s)
- Yuri Gimelfarb
- AMHC, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Bat Yam, Israel
| | - Eyal Zvi Shamir
- AMHC, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Bat Yam, Israel
| | - Keren Ness Dabush
- Assuta Medical Center, affiliated to the Faculty of Medicine, Ariel University, Ashdod, Israel
| | - Mashit Ben Tzarfati
- AMHC, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Bat Yam, Israel
| |
Collapse
|
8
|
Pearce LA, Min JE, Piske M, Zhou H, Homayra F, Slaunwhite A, Irvine M, McGowan G, Nosyk B. Opioid agonist treatment and risk of mortality during opioid overdose public health emergency: population based retrospective cohort study. BMJ 2020; 368:m772. [PMID: 32234712 PMCID: PMC7190018 DOI: 10.1136/bmj.m772] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare the risk of mortality among people with opioid use disorder on and off opioid agonist treatment (OAT) in a setting with a high prevalence of illicitly manufactured fentanyl and other potent synthetic opioids in the illicit drug supply. DESIGN Population based retrospective cohort study. SETTING Individual level linkage of five health administrative datasets capturing drug dispensations, hospital admissions, physician billing records, ambulatory care reports, and deaths in British Columbia, Canada. PARTICIPANTS 55 347 people with opioid use disorder who received OAT between 1 January 1996 and 30 September 2018. MAIN OUTCOME MEASURES All cause and cause specific crude mortality rates (per 1000 person years) to determine absolute risk of mortality and all cause age and sex standardised mortality ratios to determine relative risk of mortality compared with the general population. Mortality risk was calculated according to treatment status (on OAT, off OAT), time since starting and stopping treatment (1, 2, 3-4, 5-12, >12 weeks), and medication type (methadone, buprenorphine/naloxone). Adjusted risk ratios compared the relative risk of mortality on and off OAT over time as fentanyl became more prevalent in the illicit drug supply. RESULTS 7030 (12.7%) of 55 347 OAT recipients died during follow-up. The all cause standardised mortality ratio was substantially lower on OAT (4.6, 95% confidence interval 4.4 to 4.8) than off OAT (9.7, 9.5 to 10.0). In a period of increasing prevalence of fentanyl, the relative risk of mortality off OAT was 2.1 (95% confidence interval 1.8 to 2.4) times higher than on OAT before the introduction of fentanyl, increasing to 3.4 (2.8 to 4.3) at the end of the study period (65% increase in relative risk). CONCLUSIONS Retention on OAT is associated with substantial reductions in the risk of mortality for people with opioid use disorder. The protective effect of OAT on mortality increased as fentanyl and other synthetic opioids became common in the illicit drug supply, whereas the risk of mortality remained high off OAT. As fentanyl becomes more widespread globally, these findings highlight the importance of interventions that improve retention on opioid agonist treatment and prevent recipients from stopping treatment.
Collapse
Affiliation(s)
- Lindsay A Pearce
- Health Economic Research Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, V6Z 1Y6, Canada
| | - Jeong Eun Min
- Health Economic Research Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, V6Z 1Y6, Canada
| | - Micah Piske
- Health Economic Research Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, V6Z 1Y6, Canada
| | - Haoxuan Zhou
- Health Economic Research Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, V6Z 1Y6, Canada
| | - Fahmida Homayra
- Health Economic Research Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, V6Z 1Y6, Canada
| | - Amanda Slaunwhite
- British Columbia Centre for Disease Control and Prevention, Vancouver, BC, V5Z 4R4, Canada
| | - Mike Irvine
- British Columbia Centre for Disease Control and Prevention, Vancouver, BC, V5Z 4R4, Canada
| | - Gina McGowan
- British Columbia Ministry of Mental Health and Addictions, Victoria, BC, V8W 9P1, Canada
| | - Bohdan Nosyk
- Health Economic Research Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, V6Z 1Y6, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, V5A 1S6, Canada
| |
Collapse
|
9
|
Goldman JE, Samuels EA, Rich JD, Marshall BDL. Correlates of death during outpatient treatment for opioid use disorder: A national study. J Subst Abuse Treat 2020; 112:76-85. [PMID: 32199549 PMCID: PMC10395190 DOI: 10.1016/j.jsat.2020.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 01/08/2020] [Accepted: 01/09/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND As the burden of opioid use disorder (OUD) increases in the United States, manifold federal and state initiatives have sought to increase access to treatment for OUD, which includes behavioral and pharmaceutical treatment modalities. Although the evidence base for outpatient treatment for OUD-including medications for opioid use disorder-is substantial, few studies have examined the risk factors for fatality during treatment for OUD. METHODS Treatment Episode Data Set-Discharges (TEDS-D) data were used to evaluate correlates of death during outpatient treatment for OUD in 2016. To determine the correlates of mortality during an outpatient treatment for OUD, we constructed a pooled logistic regression model, stratified by use of medication for opioid use disorder (MOUD), to control for the duration of time in treatment and to identify the independent characteristics that may lead to differences in the odds of mortality during treatment. FINDINGS 1861 (0.8%) of 235,745 outpatient treatment episodes for OUD included in our analysis resulted in fatality. Many factors correlated with death during treatment were similar for individuals who did and did not receive MOUD. However, non-White race was only significantly associated with decreases in fatality in non-MOUD treatment episodes. Male sex and reported intravenous drug use at admission were associated with fatality only for treatment episodes that did not involve MOUD. CONCLUSIONS In this national study of outpatient treatment episodes for OUD, we found differences in age, sex, region, drug use history, treatment setting, and treatment history significantly affected the risk of death during treatment. As more people become engaged with treatment, facilities should work toward delivering optimal treatment for all patients regardless of personal characteristics.
Collapse
Affiliation(s)
- Jacqueline E Goldman
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Box G-S-121-2, Providence, RI 02912, USA
| | - Elizabeth A Samuels
- Department of Emergency Medicine, Warren Alpert School Medical School of Brown University, Providence, RI, USA
| | - Josiah D Rich
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Box G-S-121-2, Providence, RI 02912, USA; Center for Prisoner Health and Human Rights, Providence, RI, USA
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Box G-S-121-2, Providence, RI 02912, USA.
| |
Collapse
|
10
|
Bell J, Strang J. Medication Treatment of Opioid Use Disorder. Biol Psychiatry 2020; 87:82-88. [PMID: 31420089 DOI: 10.1016/j.biopsych.2019.06.020] [Citation(s) in RCA: 150] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 06/25/2019] [Accepted: 06/25/2019] [Indexed: 12/19/2022]
Abstract
Opioid use disorder (OUD) is a chronic, relapsing condition, often associated with legal, interpersonal, and employment problems. Medications demonstrated to be effective for OUD are methadone (a full opioid agonist), buprenorphine (a partial agonist), and naltrexone (an opioid antagonist). Methadone and buprenorphine act by suppressing opioid withdrawal symptoms and attenuating the effects of other opioids. Naltrexone blocks the effects of opioid agonists. Oral methadone has the strongest evidence for effectiveness. Longer duration of treatment allows restoration of social connections and is associated with better outcomes. Treatments for OUD may be limited by poor adherence to treatment recommendations and by high rates of relapse and increased risk of overdose after leaving treatment. Treatment with methadone and buprenorphine has the additional risk of diversion and misuse of medication. New depot and implant formulations of buprenorphine and naltrexone have been developed to address issues of safety and problems of poor treatment adherence. For people with OUD who do not respond to these treatments, there is accumulating evidence for supervised injectable opioid treatment (prescribing pharmaceutical heroin). Another medication mode of minimizing risk of overdose is take-home naloxone. Naloxone is an opioid antagonist used to reverse opioid overdose, and take-home naloxone programs aim to prevent fatal overdose. All medication-assisted treatment is limited by lack of access and by stigma. In seeking to stem the rising toll from OUD, expanding access to approved treatment such as methadone, for which there remains the best evidence of efficacy, may be the most useful approach.
Collapse
Affiliation(s)
- James Bell
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| |
Collapse
|
11
|
Effects of medication-assisted treatment on mortality among opioids users: a systematic review and meta-analysis. Mol Psychiatry 2019; 24:1868-1883. [PMID: 29934549 DOI: 10.1038/s41380-018-0094-5] [Citation(s) in RCA: 194] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 03/27/2018] [Accepted: 04/18/2018] [Indexed: 11/08/2022]
Abstract
Opioid use disorder (OUD) is associated with a high risk of premature death. Medication-assisted treatment (MAT) is the primary treatment for opioid dependence. We comprehensively assessed the effects of different MAT-related characteristics on mortality among those with OUD by a systematic review and meta-analysis. The all-cause and overdose crude mortality rates (CMRs) and relative risks (RRs) by treatment status, different type, period, and dose of medication, and retention time were pooled using random effects, subgroup analysis, and meta-regression. Thirty cohort studies involving 370,611 participants (1,378,815 person-years) were eligible in the meta-analysis. From 21 studies, the pooled all-cause CMRs were 0.92 per 100 person-years (95% CI: 0.79-1.04) while receiving MAT, 1.69 (1.47-1.91) after cessation, and 4.89 (3.54-6.23) for untreated period. Based on 16 studies, the pooled overdose CMRs were 0.24 (0.20-0.28) while receiving MAT, 0.68 (0.55-0.80) after cessation of MAT, and 2.43 (1.72-3.15) for untreated period. Compared with patients receiving MAT, untreated participants had higher risk of all-cause mortality (RR 2.56 [95% CI: 1.72-3.80]) and overdose mortality (8.10 [4.48-14.66]), and discharged participants had higher risk of all-cause death (2.33 [2.02-2.67]) and overdose death (3.09 [2.37-4.01]). The all-cause CMRs during and after opioid substitution treatment with methadone or buprenorphine were 0.93 (0.76-1.10) and 1.79 (1.47-2.10), and corresponding estimate for antagonist naltrexone treatment were 0.26 (0-0.59) and 1.97 (0-5.18), respectively. Retention in MAT of over 1-year was associated with a lower mortality rate than that with retention ≤1 year (1.62, 1.31-1.93 vs. 5.31, -0.09-10.71). Improved coverage and adherence to MAT and post-treatment follow-up are crucial to reduce the mortality. Long-acting naltrexone showed positive advantage on prevention of premature death among persons with OUD.
Collapse
|
12
|
Macleod J, Steer C, Tilling K, Cornish R, Marsden J, Millar T, Strang J, Hickman M. Prescription of benzodiazepines, z-drugs, and gabapentinoids and mortality risk in people receiving opioid agonist treatment: Observational study based on the UK Clinical Practice Research Datalink and Office for National Statistics death records. PLoS Med 2019; 16:e1002965. [PMID: 31770388 PMCID: PMC6879111 DOI: 10.1371/journal.pmed.1002965] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 10/24/2019] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Patients with opioid dependency prescribed opioid agonist treatment (OAT) may also be prescribed sedative drugs. This may increase mortality risk but may also increase treatment duration, with overall benefit. We hypothesised that prescription of benzodiazepines in patients receiving OAT would increase risk of mortality overall, irrespective of any increased treatment duration. METHODS AND FINDINGS Data on 12,118 patients aged 15-64 years prescribed OAT between 1998 and 2014 were extracted from the Clinical Practice Research Datalink. Data from the Office for National Statistics on whether patients had died and, if so, their cause of death were available for 7,016 of these patients. We identified episodes of prescription of benzodiazepines, z-drugs, and gabapentinoids and used linear regression and Cox proportional hazards models to assess the associations of co-prescription (prescribed during OAT and up to 12 months post-treatment) and concurrent prescription (prescribed during OAT) with treatment duration and mortality. We examined all-cause mortality (ACM), drug-related poisoning (DRP) mortality, and mortality not attributable to DRP (non-DRP). Models included potential confounding factors. In 36,126 person-years of follow-up there were 657 deaths and 29,540 OAT episodes, of which 42% involved benzodiazepine co-prescription and 29% concurrent prescription (for z-drugs these respective proportions were 20% and 11%, and for gabapentinoids 8% and 5%). Concurrent prescription of benzodiazepines was associated with increased duration of methadone treatment (adjusted mean duration of treatment episode 466 days [95% CI 450 to 483] compared to 286 days [95% CI 275 to 297]). Benzodiazepine co-prescription was associated with increased risk of DRP (adjusted HR 2.96 [95% CI 1.97 to 4.43], p < 0.001), with evidence of a dose-response effect, but showed little evidence of an association with non-DRP (adjusted HR 0.91 [95% CI 0.66 to 1.25], p = 0.549). Co-prescription of z-drugs showed evidence of an association with increased risk of DRP (adjusted HR 2.75 [95% CI 1.57 to 4.83], p < 0.001) but little evidence of an association with non-DRP (adjusted HR 0.79 [95% CI 0.49 to 1.28], p = 0.342). There was no evidence of an association of gabapentinoid co-prescription with DRP (HR 1.54 [95% CI 0.60 to 3.98], p = 0.373) but evidence of an association with increased non-DRP (HR 1.83 [95% CI 1.28 to 2.62], p = 0.001). Concurrent benzodiazepine prescription also increased mortality risk after consideration of duration of OAT (adjusted HR for DRP with benzodiazepine concurrent prescription 3.34 [95% CI 2.14 to 5.20], p < 0.001). The main limitation of this study is the possibility that unmeasured confounding factors led to an association between benzodiazepine prescription and DRP that is not causal. CONCLUSIONS In this study, co-prescription of benzodiazepine was specifically associated with increased risk of DRP in opioid-dependent individuals. Co-prescription of z-drugs and gabapentinoids was also associated with increased mortality risk; however, for z-drugs there was no evidence for a dose-response effect on DRP, and for gabapentinoids the increased mortality risk was not specific to DRP. Concurrent prescription of benzodiazepine was associated with longer treatment but still increased risk of death overall. Clinicians should be cautious about prescribing benzodiazepines to opioid-dependent individuals.
Collapse
Affiliation(s)
- John Macleod
- Population Health Sciences, Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
- * E-mail:
| | - Colin Steer
- Population Health Sciences, Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Kate Tilling
- Population Health Sciences, Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Rosie Cornish
- Population Health Sciences, Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
| | - John Marsden
- Addictions Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
| | - Tim Millar
- Centre for Mental Health & Safety, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - John Strang
- Addictions Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
| |
Collapse
|
13
|
Bahji A, Cheng B, Gray S, Stuart H. Reduction in mortality risk with opioid agonist therapy: a systematic review and meta-analysis. Acta Psychiatr Scand 2019; 140:313-339. [PMID: 31419306 DOI: 10.1111/acps.13088] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Opioid agonist therapies are effective medications that can greatly improve the quality of life of individuals with opioid use disorder. However, there is significant uncertainty about the risks of cause-specific mortality in and out of treatment. OBJECTIVE This systematic review and meta-analysis explored the association between methadone and buprenorphine with cause-specific mortality among opioid-dependent persons. METHODS We searched six online databases to identify relevant cohort studies, calculating all-cause and overdose-specific mortality rates during periods in and out of treatment. We pooled mortality estimates using multivariate random effects meta-analysis of the crude mortality rate per 1000 person-years of follow-up as well as relative risks comparing mortality in vs. out of treatment. RESULTS A total of 32 cohort studies (representing 150 235 participants, 805 423.6 person-years, and 9112 deaths) met eligibility criteria. Crude mortality rates were substantially higher among methadone cohorts than buprenorphine cohorts. Relative risk reduction was substantially higher with methadone relative to buprenorphine when time in-treatment was compared to time out-of-treatment. Furthermore, the greatest mortality reduction was conferred during the first 4 weeks of treatment. Mortality estimates were substantially heterogeneous and varied significantly by country, region, and by the nature of the treatment provider. CONCLUSION Precautions are necessary for the safer implementation of opioid agonist therapy, including baseline assessments of opioid tolerance, ongoing monitoring during the induction period, education of patients about the risk of overdose, and coordination within healthcare services.
Collapse
Affiliation(s)
- A Bahji
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.,Department of Psychiatry, Queen's University, Kingston, ON, Canada.,Substance Treatment and Recovery Team, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - B Cheng
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - S Gray
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - H Stuart
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| |
Collapse
|
14
|
Bech AB, Clausen T, Waal H, Šaltytė Benth J, Skeie I. Mortality and causes of death among patients with opioid use disorder receiving opioid agonist treatment: a national register study. BMC Health Serv Res 2019; 19:440. [PMID: 31266495 PMCID: PMC6604272 DOI: 10.1186/s12913-019-4282-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 06/19/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Mortality rates and causes of death among individuals in opioid agonist treatment (OAT) vary according to several factors such as geographical region, age, gender, subpopulations, drug culture and OAT status. Patients in OAT are ageing due to effective OAT as well as demographic changes, which has implications for morbidity and mortality. Norway has one of the oldest OAT populations in Europe. Because of the varying mortality rates and causes of death in different subgroups and countries, research gaps still exist. The aims of this study were to describe the causes of death among OAT patients in Norway, to estimate all-cause and cause-specific crude mortality rates (CMRs) during OAT and to explore characteristics associated with drug-induced cause of death compared with other causes of death during OAT. METHODS This was a national, observational register study. Data from the Norwegian Cause of Death Registry and the Norwegian Patient Registry were combined with data from medical records. We included all patients in the Norwegian OAT programme who died not more than 5 days after the last intake of OAT medication, between 1 January 2014 and 31 December 2015. RESULTS In the 2-year observation period, 200 (1.4%) of the OAT patients died. A forensic or medical autopsy was performed in 63% of the cases. The mean age at the time of death was 48.9 years (standard deviation 8.4), and 74% were men. Somatic disease was the most common cause of death (45%), followed by drug-induced death (42%), and violent death (12%). In general, CMRs increased with age, and they were higher in men and in patients taking methadone compared with buprenorphine. Increasing somatic comorbidity, measured by the Charlson comorbidity index, reduced the odds of dying of a drug-induced cause of death compared with other causes of death. CONCLUSIONS Both somatic and drug-induced causes of death were common during OAT. Improved treatment and follow-up of chronic diseases, especially in patients aged > 40 years, and continuous measures to reduce drug-induced deaths appear to be essential to reduce future morbidity and mortality burdens in this population.
Collapse
Affiliation(s)
- Anne Berit Bech
- National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Department of Mental Health, P.O. Box 104, N-2381, Brumunddal, Norway. .,Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, Oslo University, P.O. Box 1171, Blindern, N-0318, Oslo, Norway.
| | - Thomas Clausen
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, Oslo University, P.O. Box 1171, Blindern, N-0318, Oslo, Norway
| | - Helge Waal
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, Oslo University, P.O. Box 1171, Blindern, N-0318, Oslo, Norway.,National Advisory Unit on Substance Use Disorder Treatment, Oslo University Hospital, Sognsvannsveien 21, Bygg 6, P.O. Box 4959 Nydalen, N-0424, Oslo, Norway
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, Campus Ahus, Oslo University, P.O. Box 1171, Blindern, N-0318, Oslo, Norway.,Health Services Research Unit, Akershus University Hospital, P.O. Box 1000, N-1478, Lørenskog, Norway
| | - Ivar Skeie
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, Oslo University, P.O. Box 1171, Blindern, N-0318, Oslo, Norway.,Regional Psychiatric Centre Gjøvik, Innlandet Hospital Trust, Kyrre Grepps gate 11, N-2819, Gjøvik, Norway
| |
Collapse
|
15
|
Steer CD, Macleod J, Tilling K, Lim AG, Marsden J, Millar T, Strang J, Telfer M, Whitaker H, Vickerman P, Hickman M. The impact of opiate substitution treatment on mortality risk in drug addicts: a natural experiment study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Background
Opiate substitution treatment (OST) is the main treatment for people addicted to heroin and other opioid drugs. However, there is limited information on how the delivery of this treatment affects mortality risk.
Objectives
To investigate the associations of mortality risk with periods during treatment and following cessation of treatment, medication type, co-prescription of other medication and dosing regimens during titration and detoxification. The trends with time of prescribed medication, dose and treatment duration were also explored.
Design
Prospective longitudinal observational study.
Setting
UK primary care between 1998 and 2014.
Participants
A total of 12,780 patients receiving methadone, buprenorphine or dihydrocodeine.
Main outcome measures
All-cause mortality relating to 657 deaths and drug-related poisoning relating to 113 deaths.
Data sources
Clinical Practice Research Datalink with linked information on cause of death from the Office for National Statistics.
Results
For both outcomes, the lowest mortality risk was observed after 4 weeks of treatment and the highest risk was observed in the first 4 weeks following cessation of treatment [e.g. for drug-related poisoning, incidence rate ratio (IRR) 8.15, 95% confidence interval (CI) 5.45 to 12.19]. There was evidence that the treatment period risks varied with OST medication. The largest difference in risk was for the first 4 weeks of treatment for both outcomes, with patients on buprenorphine being at lower risk than those on methadone (e.g. for drug-related poisoning, IRR 0.08, 95% CI 0.01 to 0.48). The co-prescription of benzodiazepines was associated with linearly increasing the risk of drug-related deaths by dose (IRR 2.02, 95% CI 1.66 to 2.47), whereas z-drugs (zolpidem, zopiclone and zaleplon) were associated with increased risk of both all-cause (IRR 1.83, 95% CI 1.59 to 2.12) and drug-related (IRR 3.31, 95% CI 2.45 to 4.47) mortality. There was weak evidence that higher initial and final doses were associated with increased all-cause mortality risk. In the first 4 weeks of treatment, the risk increased by 4% for each 5-mg increment in methadone dose (1-mg increase in buprenorphine) (hazard ratio 1.04, 95% CI 1.00 to 1.09). In the first 4 weeks after treatment ceased, a similar increment in final dose increased the risk by 3% (hazard ratio 1.03, 95% CI 0.99 to 1.07). There were too few deaths to evaluate the effects on drug-related poisoning. The proportion of OST patients receiving buprenorphine increased between 1998 and 2006. Median treatment duration was consistently shorter for buprenorphine than for methadone for each year studied (overall median duration of 48 and 106 days, respectively).
Limitations
As this was an observational study, the possibility remains of bias from unmeasured factors, which covariate adjustment and inverse probability weighting can eliminate only partially.
Conclusions
Using buprenorphine as an alternative to methadone may not reduce mortality overall despite resulting in lower IRRs from shorter treatment duration. Clinical guidance needs to consider strengthening warnings about the co-prescription of a range of drugs for OST patients.
Future work
Our analyses need to be replicated using other clinical data sets in the UK and in other countries. New interventions and trials are required to investigate improving the retention of OST patients in primary care.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
Collapse
Affiliation(s)
- Colin D Steer
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - John Macleod
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kate Tilling
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Aaron G Lim
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - John Marsden
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Tim Millar
- Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester, UK
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | | | - Heather Whitaker
- Department of Mathematics and Statistics, The Open University, Milton Keynes, UK
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| |
Collapse
|
16
|
Frauger E, Fouilhé Sam-Laï N, Mallaret M, Micallef J. [Improve the benefit/risk balance of methadone by respecting its pharmacological specificities]. Therapie 2018; 74:383-388. [PMID: 31178032 DOI: 10.1016/j.therap.2018.09.070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 09/04/2018] [Accepted: 09/18/2018] [Indexed: 01/04/2023]
Abstract
Recent data on methadone from 2008 to 2017 by the French addictovigilance network warms on the increase of methadone use, its diversion, its increase of overdose risk factors (opioids associated, occasional use) and deaths. Whereas methadone is an essential drug for opioid addiction, its use remains complex because of its pharmacology leading to increase the awareness of health professionals.
Collapse
Affiliation(s)
- Elisabeth Frauger
- Inserm, service de pharmacologie clinique et pharmacovigilance, centre d'addictovigilance PACA-Corse, institut de neurosciences des systèmes, Aix-Marseille université, AP-HM, 13005, Marseille, France.
| | | | - Michel Mallaret
- Centre d'addictovigilance, CHU de Grenoble-Alpes, 38043 Grenoble, France
| | - Joëlle Micallef
- Inserm, service de pharmacologie clinique et pharmacovigilance, centre d'addictovigilance PACA-Corse, institut de neurosciences des systèmes, Aix-Marseille université, AP-HM, 13005, Marseille, France
| | | |
Collapse
|
17
|
Hickman M, Steer C, Tilling K, Lim AG, Marsden J, Millar T, Strang J, Telfer M, Vickerman P, Macleod J. The impact of buprenorphine and methadone on mortality: a primary care cohort study in the United Kingdom. Addiction 2018; 113:1461-1476. [PMID: 29672985 PMCID: PMC6282737 DOI: 10.1111/add.14188] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 12/28/2017] [Accepted: 02/05/2018] [Indexed: 01/18/2023]
Abstract
AIMS To estimate whether opioid substitution treatment (OST) with buprenorphine or methadone is associated with a greater reduction in the risk of all-cause mortality (ACM) and opioid drug-related poisoning (DRP) mortality. DESIGN Cohort study with linkage between clinical records from Clinical Practice Research Datalink and mortality register. SETTING UK primary care. PARTICIPANTS A total of 11 033 opioid-dependent patients who received OST from 1998 to 2014, followed-up for 30 410 person-years. MEASUREMENTS Exposure to methadone (17 373, 61%) OST episodes or buprenorphine (9173, 39%) OST episodes. ACM was available for all patients; information on cause of death and DRP was available for 5935 patients (54%) followed-up for 16 363 person-years. Poisson regression modelled mortality by treatment period with an interaction between OST type and treatment period (first 4 weeks on OST, rest of time off OST, first 4 weeks off OST, rest of time out of OST censored at 12 months) to test whether ACM or DRP differed between methadone and buprenorphine. Inverse probability weights were included to adjust for confounding and balance characteristics of patients prescribed methadone or buprenorphine. FINDINGS ACM and DRP rates were 1.93 and 0.53 per 100 person-years, respectively. DRP was elevated during the first 4 weeks of OST [incidence rate ratio (IRR) = 1.93 95% confidence interval (CI) = 0.97-3.82], the first 4 weeks off OST (IRR = 8.15, 95% CI = 5.45-12.19) and the rest of time out of OST (IRR = 2.13, 95% CI = 1.47-3.09) compared with mortality risk from 4 weeks to end of treatment. Patients on buprenorphine compared with methadone had lower ACM rates in each treatment period. After adjustment, there was evidence of a lower DRP risk for patients on buprenorphine compared with methadone at treatment initiation (IRR = 0.08, 95% CI = 0.01-0.48) and rest of time on treatment (IRR = 0.37, 95% CI = 0.17-0.79). Treatment duration (mean and median) was shorter on buprenorphine than methadone (173 and 40 versus 363 and 111, respectively). Model estimates suggest that there was a low probability that methadone or buprenorphine reduced the number of DRP in the population: 28 and 21%, respectively. CONCLUSIONS In UK general medical practice, opioid substitution treatment with buprenorphine is associated with a lower risk of all-cause and drug-related poisoning mortality than methadone. In the population, buprenorphine is unlikely to give greater overall protection because of the relatively shorter duration of treatment.
Collapse
Affiliation(s)
- Matthew Hickman
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Colin Steer
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Kate Tilling
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Aaron G. Lim
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - John Marsden
- Addictions Department, Institute of Psychiatry, Psychiatry and NeuroscienceKing's College LondonLondonUK
| | - Tim Millar
- Centre for Mental Health and Safety, School of Health SciencesThe University of ManchesterManchesterUK
| | - John Strang
- Addictions Department, Institute of Psychiatry, Psychiatry and NeuroscienceKing's College LondonLondonUK
| | | | - Peter Vickerman
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - John Macleod
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| |
Collapse
|
18
|
Walton G, Dong H, Milloy MJ, DeBeck K, Kerr T, Wood E, Hayashi K. Increasing availability of benzodiazepines among people who inject drugs in a Canadian setting. Subst Abus 2018; 39:69-76. [PMID: 28727956 DOI: 10.1080/08897077.2017.1356798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Benzodiazepine misuse is associated with mortality and is common among people who inject drugs (PWID). This study aimed to examine the temporal trends in the availability of benzodiazepines among PWID in a Canadian setting, and to identify factors associated with more immediate access to benzodiazepines. METHODS Data were derived from 3 prospective cohorts of PWID in Vancouver, Canada, between June 2012 and May 2015. The primary outcome was the perceived availability of benzodiazepines, measured in 3 levels: not available, delayed availability (available in ≥10 minutes), and immediate availability (available in <10 minutes). The authors used multivariable generalized estimating equations to identify factors associated with availability of benzodiazepines. RESULTS In total, 1641 individuals were included in these analyses. In multivariable analyses, factors associated with immediate benzodiazepine availability included incarceration (adjusted odds ratio [AOR]: 1.42, 95% confidence interval [CI]: 1.06, 1.89) and participation in methadone maintenance therapy (MMT) (AOR: 1.35, 95% CI: 1.14, 1.60). Factors associated with delayed benzodiazepine availability included incarceration (AOR: 1.45, 95% CI: 1.02, 2.07) and participation in MMT (AOR: 1.77, 95% CI: 1.48, 2.12). Benzodiazepine availability increased throughout the study period for both immediate (AOR: 1.14, 95% CI: 1.10, 1.18 per 6-month follow-up period) and delayed (AOR: 1.17, 95% CI: 1.12, 1.22 per 6-month follow-up period) availability. CONCLUSIONS Among our sample of PWID, benzodiazepine availability is increasing and was associated with health and criminal justice system characteristics. Our findings indicate a need to examine prescribing practices and educate both PWID and health care providers about the risks associated with benzodiazepine use.
Collapse
Affiliation(s)
- Geoffrey Walton
- a British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital , Vancouver , British Columbia , Canada.,b Department of Medicine , University of British Columbia , Vancouver , British Columbia , Canada
| | - Huiru Dong
- a British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital , Vancouver , British Columbia , Canada
| | - M J Milloy
- a British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital , Vancouver , British Columbia , Canada.,b Department of Medicine , University of British Columbia , Vancouver , British Columbia , Canada
| | - Kora DeBeck
- a British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital , Vancouver , British Columbia , Canada.,c School of Public Policy , Simon Fraser University , Vancouver , British Columbia , Canada
| | - Thomas Kerr
- a British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital , Vancouver , British Columbia , Canada
| | - Evan Wood
- a British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital , Vancouver , British Columbia , Canada.,b Department of Medicine , University of British Columbia , Vancouver , British Columbia , Canada
| | - Kanna Hayashi
- a British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital , Vancouver , British Columbia , Canada.,d Faculty of Health Sciences , Simon Fraser University , Burnaby , British Columbia , Canada
| |
Collapse
|
19
|
Marsden J, Stillwell G, Jones H, Cooper A, Eastwood B, Farrell M, Lowden T, Maddalena N, Metcalfe C, Shaw J, Hickman M. Does exposure to opioid substitution treatment in prison reduce the risk of death after release? A national prospective observational study in England. Addiction 2017; 112:1408-1418. [PMID: 28160345 DOI: 10.1111/add.13779] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 01/11/2017] [Accepted: 02/01/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS People with opioid use disorder (OUD) in prison face an acute risk of death after release. We estimated whether prison-based opioid substitution treatment (OST) reduces this risk. DESIGN Prospective observational cohort study using prison health care, national community drug misuse treatment and deaths registers. SETTING Recruitment at 39 adult prisons in England (32 male; seven female) accounting for 95% of OST treatment in England during study planning. PARTICIPANTS Adult prisoners diagnosed with OUD (recruited: September 2010-August 2013; first release: September 2010; last release: October 2014; follow-up to February 2016; n = 15 141 in the risk set). INTERVENTION AND COMPARATOR At release, participants were classified as OST exposed (n = 8645) or OST unexposed (n = 6496). The OST unexposed group did not receive OST, or had been withdrawn, or had a low dose. MEASUREMENTS Primary outcome: all-cause mortality (ACM) in the first 4 weeks. SECONDARY OUTCOMES drug-related poisoning (DRP) deaths in the first 4 weeks; ACM and DRP mortality after 4 weeks to 1 year; admission to community drug misuse treatment in the first 4 weeks. Unadjusted and adjusted Cox regression models (covariates: sex, age, drug injecting, problem alcohol use, use of benzodiazepines, cocaine, prison transfer and admission to community treatment), tested difference in mortality rates and community treatment uptake. FINDINGS During the first 4 weeks after prison release there were 24 ACM deaths: six in the OST exposed group and 18 in the OST unexposed group [mortality rate 0.93 per 100 person-years (py) versus 3.67 per 100 py; hazard ratio (HR) = 0.25; 95% confidence interval (CI) = 0.10-0.64]. There were 18 DRP deaths: OST exposed group mortality rate 0.47 per 100 py versus 3.06 per 100 py in the OST unexposed group (HR = 0.15; 95% CI = 0.04-0.53). There was no group difference in mortality risk after the first month. The OST exposed group was more likely to enter drug misuse treatment in the first month post-release (odds ratio 2.47, 95% CI = 2.31-2.65). The OST mortality protective effect on ACM and DRP mortality risk was not attenuated by demographic, overdose risk factors, prison transfer or community treatment (fully adjusted HR = 0.25; 95% CI = 0.09-0.64 and HR = 0.15; 95% CI = 0.04-0.52, respectively). CONCLUSIONS In an English national study, prison-based opioid substitution therapy was associated with a 75% reduction in all-cause mortality and an 85% reduction in fatal drug-related poisoning in the first month after release.
Collapse
Affiliation(s)
- John Marsden
- Addictions Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Garry Stillwell
- Addictions Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Hayley Jones
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Alisha Cooper
- Alcohol, Drug and Tobacco Division, Health and Wellbeing Directorate, Public Health England, London, UK
| | - Brian Eastwood
- Alcohol, Drug and Tobacco Division, Health and Wellbeing Directorate, Public Health England, London, UK
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, New South Wales, Australia
| | - Tim Lowden
- Alcohol, Drug and Tobacco Division, Health and Wellbeing Directorate, Public Health England, London, UK
| | - Nino Maddalena
- Alcohol, Drug and Tobacco Division, Health and Wellbeing Directorate, Public Health England, London, UK
| | - Chris Metcalfe
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Jenny Shaw
- Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK
| | - Matthew Hickman
- School of Social and Community Medicine, Faculty of Health Sciences, University of Bristol, Bristol, UK
| |
Collapse
|
20
|
Kidd B, Matthews C. Commentary on Marsden et al. (2017): While epidemiological studies can help to identify areas of overdose risk, we need more focused hypothesis-driven trials to inform clinical intervention strategies. Addiction 2017; 112:1419-1420. [PMID: 28691273 DOI: 10.1111/add.13857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 05/03/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Brian Kidd
- Division of Neuroscience, University of Dundee Medical School, Dundee, UK
| | - Christine Matthews
- Division of Neuroscience, University of Dundee Medical School, Dundee, UK
| |
Collapse
|
21
|
Bell J, Waal RVD, Strang J. Supervised Injectable Heroin: A Clinical Perspective. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2017; 62:451-456. [PMID: 28683227 PMCID: PMC5528983 DOI: 10.1177/0706743716673966] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Six recent randomised control trials (RCTs) have suggested that supervised injectable heroin (SIH) can be effective in patients who persist in street heroin use during methadone treatment. However, short-term randomised control trials have limitations in assessing the effectiveness of treatments for addictive disorders, which are chronic and relapsing disorders of motivation. These RCTs particularly fail to capture the process of the SIH treatment and the diversity of influence and change over time. METHOD This narrative review is based on the analysis of published data. Conclusions are drawn from a process of reflection informed by experience in delivering one of the published trials, subsequent experiences in varying the way SIH is delivered, and through consideration of possible mechanisms of action of SIH. OBSERVATIONS Many long-term, socially marginalised and demoralised people who are addicted to heroin experience few rewards from the stability afforded by methadone treatment. Supervised injected heroin is sufficiently reinforcing for many of these individuals to attend daily and participate in highly structured treatment. With an adequate daily dose of supervised methadone to avoid withdrawal dysphoria, occasional diamorphine injections-not necessarily twice daily, or even every day-is enough to hold people in treatment. Participation was associated with reduced amounts of non-prescribed drug use, a gradual change in self-image and attitude, and for some subjects, a movement towards social reintegration and eventual withdrawal from SIH. CONCLUSIONS Prescribed heroin is sufficiently motivating to hold a proportion of recidivist addicts in long-term treatment. Participation in structured treatment provides respite from compulsive drug use, and a proportion of subjects develop sufficient rewards from social reintegration to successfully withdraw from treatment. Such change, when it occurs, is slow and stuttering.
Collapse
Affiliation(s)
- James Bell
- 1 National Addiction Centre, Kings College London, London, United Kingdom.,2 South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Rob van der Waal
- 1 National Addiction Centre, Kings College London, London, United Kingdom.,2 South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - John Strang
- 1 National Addiction Centre, Kings College London, London, United Kingdom.,2 South London and Maudsley NHS Foundation Trust, London, United Kingdom
| |
Collapse
|
22
|
Abrahamsson T, Berge J, Öjehagen A, Håkansson A. Benzodiazepine, z-drug and pregabalin prescriptions and mortality among patients in opioid maintenance treatment-A nation-wide register-based open cohort study. Drug Alcohol Depend 2017; 174:58-64. [PMID: 28315808 DOI: 10.1016/j.drugalcdep.2017.01.013] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 01/05/2017] [Accepted: 01/08/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Use of sedatives may increase risk of death in opioid users. The aim of the study was to assess whether prescription of sedatives may be associated with mortality in patients in opioid maintenance treatment. METHODS This retrospective register-based open cohort study included nation-wide register data including all individuals who were dispensed methadone or buprenorphine as opioid maintenance treatment for opioid dependence between July, 2005 and December, 2012 (N=4501). Outcome variables were overdose mortality and non-overdose mortality, respectively. Extended Cox regression analyses examined associations between type of sedative prescriptions and death, controlling for sex, age, previous overdoses and suicide attempts, psychiatric in-patient treatment and opioid maintenance treatment status. Opioid maintenance was assumed to last for 90days (or 30days in a sensitivity analysis) after the last methadone or buprenorphine prescription. RESULTS Benzodiazepine prescriptions were associated with non-overdose death (HR: 2.02, 95% CI: 1.29-3.18) but not significantly associated with overdose death (1.49, 0.97-2.29). Z-drug (1.60, 1.07-2.39) and pregabalin prescriptions (2.82, 1.79-4.43) were associated with overdose death. In the sensitivity analysis, all categories of sedatives, including benzodiazepines, were significantly associated with overdose death. CONCLUSIONS Caution is advised when prescribing sedative drugs, including benzodiazepines, z-drugs and pregabalin, to patients in opioid maintenance treatment.
Collapse
Affiliation(s)
- Tove Abrahamsson
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Psychiatry, Lund, Sweden
| | - Jonas Berge
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Psychiatry, Lund, Sweden
| | - Agneta Öjehagen
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Psychiatry, Lund, Sweden
| | - Anders Håkansson
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Psychiatry, Lund, Sweden.
| |
Collapse
|
23
|
Luo X, Gong X, Zhao P, Zou X, Chen W, Ling L. Positive percentages of urine morphine tests among methadone maintenance treatment clients with HIV/AIDS: a 12-month follow-up study in Guangdong Province, China. BMJ Open 2017; 7:e014237. [PMID: 28450464 PMCID: PMC5566940 DOI: 10.1136/bmjopen-2016-014237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 03/10/2017] [Accepted: 03/13/2017] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE We aimed to assess the positive percentages of urine morphine tests and correlates among methadone maintenance treatment (MMT) clients with HIV/AIDS in Guangdong, China. SETTING Fourteen MMT clinics located in nine cities of Guangdong were chosen as study sites. PARTICIPANTS In this study, we reviewed 293 clients with opioid dependence, who were HIV seropositive, 18 years or older, provided informed consent and had at least 10 records of urine morphine tests during the study period. PRIMARY AND SECONDARY OUTCOME MEASURES The positive percentages of urine morphine tests were calculated and underlying predictors were estimated. RESULTS The highest positive percentage (95.9%) was observed in the first month. After excluding the highest percentage in the first month, the average positive percentage was 40.9% for month 2 to month 12. Positive percentages of urine morphine tests that were <20%, 20-60% and >80% were 25.4%, 36.1% and 38.5% respectively. Lower percentages of continued heroin use were associated with being young (OR≤30=0.31, 95% CI 0.12 to 0.78; OR31-=0.44, 95% CI 0.20 to 1.00), and financial sources depending on family or friends (OR=0.55, 95% CI 0.32 to 0.93). Higher percentages of continued heroin use were associated with being unemployed (OR=1.99, 95% CI 1.13 to 3.49) and poor MMT attendance (OR<20%=3.60, 95% CI 1.55 to 8.33; OR20%-=2.80, 95% CI 1.48 to 5.33). CONCLUSIONS High positive percentages of urine morphine tests remain prevalent among MMT clients with HIV/AIDS in Guangdong. The present findings have implications for taking effective measures to facilitate attendance in order to decrease heroin use and ultimately improve the effectiveness among these sub-group MMT clients.
Collapse
Affiliation(s)
- Xiaofeng Luo
- Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen Center for Migrant Health Policy, Sun Yat-Sen University, Guangzhou, China
| | - Xiao Gong
- Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen Center for Migrant Health Policy, Sun Yat-Sen University, Guangzhou, China
| | - Peizhen Zhao
- Guangdong Provincial Center for Skin Disease and STI Control, Guangzhou, China
| | - Xia Zou
- Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen Center for Migrant Health Policy, Sun Yat-Sen University, Guangzhou, China
| | - Wen Chen
- Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen Center for Migrant Health Policy, Sun Yat-Sen University, Guangzhou, China
| | - Li Ling
- Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen Center for Migrant Health Policy, Sun Yat-Sen University, Guangzhou, China
| |
Collapse
|
24
|
Sordo L, Barrio G, Bravo MJ, Indave BI, Degenhardt L, Wiessing L, Ferri M, Pastor-Barriuso R. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ 2017; 357:j1550. [PMID: 28446428 PMCID: PMC5421454 DOI: 10.1136/bmj.j1550] [Citation(s) in RCA: 1006] [Impact Index Per Article: 143.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Objective To compare the risk for all cause and overdose mortality in people with opioid dependence during and after substitution treatment with methadone or buprenorphine and to characterise trends in risk of mortality after initiation and cessation of treatment.Design Systematic review and meta-analysis.Data sources Medline, Embase, PsycINFO, and LILACS to September 2016.Study selection Prospective or retrospective cohort studies in people with opioid dependence that reported deaths from all causes or overdose during follow-up periods in and out of opioid substitution treatment with methadone or buprenorphine.Data extraction and synthesis Two independent reviewers performed data extraction and assessed study quality. Mortality rates in and out of treatment were jointly combined across methadone or buprenorphine cohorts by using multivariate random effects meta-analysis.Results There were 19 eligible cohorts, following 122 885 people treated with methadone over 1.3-13.9 years and 15 831 people treated with buprenorphine over 1.1-4.5 years. Pooled all cause mortality rates were 11.3 and 36.1 per 1000 person years in and out of methadone treatment (unadjusted out-to-in rate ratio 3.20, 95% confidence interval 2.65 to 3.86) and reduced to 4.3 and 9.5 in and out of buprenorphine treatment (2.20, 1.34 to 3.61). In pooled trend analysis, all cause mortality dropped sharply over the first four weeks of methadone treatment and decreased gradually two weeks after leaving treatment. All cause mortality remained stable during induction and remaining time on buprenorphine treatment. Overdose mortality evolved similarly, with pooled overdose mortality rates of 2.6 and 12.7 per 1000 person years in and out of methadone treatment (unadjusted out-to-in rate ratio 4.80, 2.90 to 7.96) and 1.4 and 4.6 in and out of buprenorphine treatment.Conclusions Retention in methadone and buprenorphine treatment is associated with substantial reductions in the risk for all cause and overdose mortality in people dependent on opioids. The induction phase onto methadone treatment and the time immediately after leaving treatment with both drugs are periods of particularly increased mortality risk, which should be dealt with by both public health and clinical strategies to mitigate such risk. These findings are potentially important, but further research must be conducted to properly account for potential confounding and selection bias in comparisons of mortality risk between opioid substitution treatments, as well as throughout periods in and out of each treatment.
Collapse
Affiliation(s)
- Luis Sordo
- National Centre for Epidemiology, Carlos III Institute of Health, Madrid, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Gregorio Barrio
- National School of Public Health, Carlos III Institute of Health, 28029 Madrid, Spain
| | - Maria J Bravo
- National Centre for Epidemiology, Carlos III Institute of Health, Madrid, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - B Iciar Indave
- National Centre for Epidemiology, Carlos III Institute of Health, Madrid, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sidney, Australia
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Lucas Wiessing
- Sector Best Practices, Knowledge Exchange and Economic Issues, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal
| | - Marica Ferri
- Sector Best Practices, Knowledge Exchange and Economic Issues, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal
| | - Roberto Pastor-Barriuso
- National Centre for Epidemiology, Carlos III Institute of Health, Madrid, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
| |
Collapse
|
25
|
Bakker A, Streel E. Benzodiazepine maintenance in opiate substitution treatment: Good or bad? A retrospective primary care case-note review. J Psychopharmacol 2017; 31:62-66. [PMID: 28072037 DOI: 10.1177/0269881116675508] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Co-prescribing benzodiazepines to patients in opiate substitution treatment is controversial and often alleged to increase mortality. In an inner-London general practice, patients with problematic benzodiazepine co-dependence were allowed benzodiazepine maintenance treatment (BMT) since 1994, providing an opportunity for analysis. METHOD 1) Case-note review of all 278 opiate substitution treatment patients, accruing 1289 patient treatment years; 46% had concurrent BMT. 2) National Health Service database search for patients who died after leaving accrued a further 883 years of information; only patients who left the UK were unaccounted for (4%). Three groups were studied: 1) never obtained benzodiazepine prescription (NOB): n=80); 2) briefly/occasionally prescribed benzodiazepines (BOP): n=71; 3) BMT: n=127. OUTCOMES MEASURED Treatment retention (months); deaths/100 patient treatment years; deaths after leaving the service/100 years of information. RESULTS Treatment retention: NOB: 34 months; BOP: 51 months; BMT: 72 months. In-treatment mortality: NOB: 1.79/100 patient treatment years; BOP: 0.33/100 patient treatment years; BMT: 1.31/100 patient treatment years. Deaths after leaving service: NOB: 2.24/100 years of information, BOP: 0.63/100 years of information. However, mortality for previously BMT-patients increased by 450% to 5.90/100 years of information. DISCUSSION BMT patients had longer treatment retention than NOB or BOP and lower mortality than NOB patients. It is unlikely that patients had access to prescribed benzodiazepines on leaving the service because of restrictions in the national guidelines but co-dependent patients are a high-risk group who may stand to gain most benefit from opiate substitution treatment if combined with benzodiazepine-maintenance.
Collapse
|
26
|
Reddy A, Schuler US, de la Cruz M, Yennurajalingam S, Wu J, Liu D, Bruera E. Overall Survival among Cancer Patients Undergoing Opioid Rotation to Methadone Compared to Other Opioids. J Palliat Med 2016; 20:656-661. [PMID: 27997283 DOI: 10.1089/jpm.2016.0316] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Methadone has been associated with lower overall survival (OS) in patients with chronic pain. There are no data available on the association of methadone with OS in cancer patients. OBJECTIVE Our aim was to compare the OS in cancer outpatients undergoing opioid rotation (OR) to methadone and other strong opioids. DESIGN Demographics, symptoms, and morphine equivalent daily dose (MEDD) were collected in patients who underwent OR from strong opioids to either methadone or other strong opioids and returned for a follow-up within six weeks. SETTING/SUBJECTS Nine hundred thirty-eight consecutive outpatients to the supportive care center of a tertiary cancer center were reviewed. MEASUREMENTS Kaplan-Meier curves were used to evaluate survival. RESULTS Of a total of 164 eligible patients, 54/76 patients who underwent OR to methadone and 48/88 patients who underwent OR to other opioids returned for a follow-up visit. The median age was 56 years, 54% were male, and 87% had advanced cancer. There were no significant differences between the two groups in patient characteristics, performance status, MEDD, and pain scores. The Kaplan-Meier curves revealed no significant difference in median OS between all patients undergoing OR to methadone and other opioids [3.75 months (95% confidence interval, CI, 2.30-6.46) vs. 2.62 months (95% CI 1.74-4.33); p = 0.35] and also among those who returned for a follow-up following an OR to methadone and other opioids [5.15 months (95% CI 3.64-7.41) vs. 5.90 months (95% CI 2.62-9.28); p = 0.89]. CONCLUSIONS We observed no significant difference in OS in cancer patients in methadone group compared to other opioids.
Collapse
Affiliation(s)
- Akhila Reddy
- 1 Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Ulrich S Schuler
- 2 Universitätsklinikum Carl Gustav Carus , PalliativCentrum & Medizinische Klinik, Dresden, Germany
| | - Maxine de la Cruz
- 1 Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Sriram Yennurajalingam
- 1 Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Jimin Wu
- 3 Department of Biostatistics, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Diane Liu
- 3 Department of Biostatistics, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Eduardo Bruera
- 1 Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center , Houston, Texas
| |
Collapse
|
27
|
Ducoffe AR, York A, Hu DJ, Perfetto D, Kerns RD. National Action Plan for Adverse Drug Event Prevention: Recommendations for Safer Outpatient Opioid Use. PAIN MEDICINE (MALDEN, MASS.) 2016; 17:2291-2304. [PMID: 28025363 PMCID: PMC6280931 DOI: 10.1093/pm/pnw106] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Adverse drug events (ADEs) have been highlighted as a major patient safety and public health challenge by the National Action Plan for Adverse Drug Event Prevention (ADE Action Plan), which was released by the Office of Disease Prevention and Health Promotion (ODPHP) in August 2014. The ADE Action Plan focuses on surveillance, evidence-based prevention, incentives, and oversights, additional research needs as well as possible measures and metrics to track progress of ADE prevention within three drug classes: anticoagulants, diabetes agents, and opioids.Objectives and Recommendations. With outpatient opioid prescriptions being a great concern among many healthcare providers, this article focuses on recommendations from the ADE Action Plan to help guide safer opioid use in healthcare delivery settings. Its aim is to discuss current federal methods in place to prevent opioid ADEs while also providing evidence to encourage providers and hospitals to innovate new systems and practices to increase prevention.
Collapse
Affiliation(s)
- Aaron R Ducoffe
- *Previously with Office of Disease Prevention and Health Promotion (ODPHP), US Department of Health and Human Services, Washington, DC; Currently with MedStar Georgetown University Hospital, Department of Radiology, Washington, DC
| | - Andrew York
- Previously with ODPHP, Washington, DC; Currently with Centers for Medicare & Medicaid Services, Baltimore, Maryland
| | - Dale J Hu
- Previously with ODPHP, Washington, DC; Currently with National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland
| | | | - Robert D Kerns
- Previously with the Pain Research, Informatics, Multi-Morbidities and Education (PRIME) Center, Virginia Connecticut Healthcare System, West Haven, Connecticut; Currently with Yale University, New Haven, Connecticut, USA
| |
Collapse
|
28
|
Gao L, Dimitropoulou P, Robertson JR, McTaggart S, Bennie M, Bird SM. Risk-factors for methadone-specific deaths in Scotland's methadone-prescription clients between 2009 and 2013. Drug Alcohol Depend 2016; 167:214-23. [PMID: 27593969 PMCID: PMC5047032 DOI: 10.1016/j.drugalcdep.2016.08.627] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 08/01/2016] [Accepted: 08/22/2016] [Indexed: 01/31/2023]
Abstract
AIM To quantify gender, age-group and quantity of methadone prescribed as risk factors for drugs-related deaths (DRDs), and for methadone-specific DRDs, in Scotland's methadone-prescription clients. DESIGN Linkage to death-records for Scotland's methadone-clients with one or more Community Health Index (CHI)-identified methadone prescriptions during July 2009 to June 2013. SETTING Scotland's Prescribing Information System and National Records of Scotland. MEASUREMENTS Covariates defined at first CHI-identified methadone prescription, and person-years at-risk (pys) thereafter until the earlier of death-date or 31 December 2013. Methadone-specific DRDs were defined as: methadone implicated but neither heroin nor buprenorphine. Hazard ratios (HRs) were assessed using proportional hazards regression. FINDINGS Scotland's CHI-identified methadone-prescription cohort comprised 33,128 clients, 121,254 pys, 1,171 non-DRDs and 760 DRDs (6.3 per 1,000 pys), of which 362 were methadone-specific. Irrespective of gender, methadone-specific DRD-rate, per 1,000 pys, was higher in the 35+ age-group (4.2; 95% CI: 3.6-4.7) than for younger clients (1.9; 95% CI: 1.5-2.2). For methadone-specific DRDs, age-related HRs (e.g., 2.9 at 45+ years; 95% CI: 2.1-3.9) were steeper than for all DRDs (1.9; 95% CI: 1.5-2.4); there was no hazard-reduction for females; no gender by age-group interaction; and, unlike for all DRDs, the highest quintile for quantity of prescribed methadone at cohort-entry (>1960mg) was associated with increased HR (1.8; 95% CI: 1.3-2.5). CONCLUSION Higher methadone-specific DRD rates in older clients, irrespective of gender, call for better understanding of methadone's pharmaco-dynamics in older, opioid-dependent clients, many with progressive physical or mental ill-health.
Collapse
Affiliation(s)
- Lu Gao
- MRC Biostatistics Unit, Cambridge CB2 0SR, United Kingdom
| | | | - J Roy Robertson
- Usher Institute of Population Health Sciences and Informatics, Edinburgh University, EDINBURGH EH16 4UX, United Kingdom
| | - Stuart McTaggart
- Information Services Division, NHS National Services Scotland, Edinburgh EH12 9EB, United Kingdom
| | - Marion Bennie
- Information Services Division, NHS National Services Scotland, Edinburgh EH12 9EB, United Kingdom; Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow G4 0RE, United Kingdom
| | - Sheila M Bird
- MRC Biostatistics Unit, Cambridge CB2 0SR, United Kingdom; Department of Mathematics and Statistics, Strathclyde University, Glasgow G1 1XH, United Kingdom.
| |
Collapse
|
29
|
Bogdanowicz KM, Stewart R, Chang CK, Downs J, Khondoker M, Shetty H, Strang J, Hayes RD. Identifying mortality risks in patients with opioid use disorder using brief screening assessment: Secondary mental health clinical records analysis. Drug Alcohol Depend 2016; 164:82-88. [PMID: 27179824 PMCID: PMC4907127 DOI: 10.1016/j.drugalcdep.2016.04.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/07/2016] [Accepted: 04/27/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Risk assessments are widely used, but their ability to predict outcomes in opioid use disorder (OUD) treatment remains unclear. Therefore, the aim was to investigate if addiction-specific brief risk screening is effective in identifying high mortality risk groups and if subsequent clinical actions following risk assessment impacts on mortality levels. METHODS Opioid use disorder (OUD) patients were identified in the South London and Maudsley Case Register. Deaths were identified through database linkage to the national mortality dataset. Cox and competing-risk regression were used to model associations between brief risk assessment domains and all-cause and overdose mortality in 4488 OUD patients, with up-to 6-year follow-up time where 227 deaths were registered. Data were stratified by admission to general mental health services. RESULTS All-cause mortality was significantly associated with unsafe injecting (HR 1.53, 95% CI 1.10-2.11) and clinically appraised likelihood of accidental overdose (HR 1.48, 95% CI 1.00-2.19). Overdose-mortality was significantly associated with unsafe injecting (SHR 2.52, 95% CI 1.11-5.70) and clinically appraised suicidality (SHR 2.89, 95% CI 1.38-6.03). Suicidality was associated with a twofold increase in mortality risk among OUD patients who were not admitted to mental health services within 2 months of their risk assessment (HR 2.03, 95% CI 1.67-3.24). CONCLUSIONS Diagnosis-specific brief risk screening can identify OUD patient subgroups at increased risk of all-cause and overdose mortality. OUD patients, where suicidality is evident, who are not admitted into services are particularly vulnerable.
Collapse
Affiliation(s)
| | - Robert Stewart
- King's College London, Institute of Psychiatry Psychology and Neuroscience, London SE5 8AF, UK
| | - Chin-Kuo Chang
- King's College London, Institute of Psychiatry Psychology and Neuroscience, London SE5 8AF, UK
| | - Johnny Downs
- King's College London, Institute of Psychiatry Psychology and Neuroscience, London SE5 8AF, UK
| | - Mizanur Khondoker
- King's College London, Institute of Psychiatry Psychology and Neuroscience, London SE5 8AF, UK; University College London, Institute of Epidemiology and Health, UK
| | - Hitesh Shetty
- University College London, Institute of Epidemiology and Health, UK
| | - John Strang
- King's College London, Institute of Psychiatry Psychology and Neuroscience, London SE5 8AF, UK; South London and Maudsley NHS Foundation Trust, London SE5 8AZ, UK
| | - Richard Derek Hayes
- King's College London, Institute of Psychiatry Psychology and Neuroscience, London SE5 8AF, UK
| |
Collapse
|
30
|
Study protocol of the ESUB-MG cluster randomized trial: a pragmatic trial assessing the implementation of urine drug screening in general practice for buprenorphine maintained patients. BMC FAMILY PRACTICE 2016; 17:24. [PMID: 26931763 PMCID: PMC4774159 DOI: 10.1186/s12875-016-0413-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 01/22/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND In addiction care, urine drug screening tests are recommended to assess psychoactive substances use. While intrinsic diagnostic value of these tests is demonstrated, the consequences of carrying out these tests on opiate maintenance treatment (OMT) have not been established. The main objective will be to assess the impact of on-site urine drug screening tests (OS-UDS) in general practice compared to routine medical care on OMT retention at 6 months in opioid-dependent patients initiating buprenorphine. METHODS/DESIGN The ESUB-MG study uses a pragmatic, cluster randomized controlled trial design. General Practitioners (GPs) regularly managing patients treated with buprenorphine and consenting for participating will be invited to participate. GPs will be randomly assigned to one of two groups for 6 to 24 months: (a) control group (usual care: standard medical strategy for assessing drug use); (b) interventional group (including 1/ a training session on practice and interpretation of OS-UDS; 2/ the supply of OS-UDS at GPs' medical offices; 3/ performing an OS-UDS before the first prescription of buprénorphine). GPs will have to include 1 to 10 patients aged 18 years-old or more, consulting for starting treatment by buprenorphine, not opposed to participate. The primary outcome will be OMT retention at 6 months. DISCUSSION This randomized interventional trial should bring sufficient level of evidence to assess effectiveness of performing OS-UDS in general practice for patients treated by buprenorphine. Training GPs to drug tests and supplying them in their office should lead to an improvement of opioid-addicted patients' care through helping decision. TRIALS REGISTRATION NCT02345655 (first registration May 14, 2014).
Collapse
Affiliation(s)
- The ESUB-MG Study Group
- Département Universitaire de Médecine Générale, Université de Toulouse III, Faculté de Médecine, 133 route de Narbonne, 31062 Toulouse, France
| |
Collapse
|
31
|
Pierce M, Bird SM, Hickman M, Marsden J, Dunn G, Jones A, Millar T. Impact of treatment for opioid dependence on fatal drug-related poisoning: a national cohort study in England. Addiction 2016; 111:298-308. [PMID: 26452239 PMCID: PMC4950033 DOI: 10.1111/add.13193] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 08/20/2015] [Accepted: 10/06/2015] [Indexed: 11/29/2022]
Abstract
AIMS To compare the change in illicit opioid users' risk of fatal drug-related poisoning (DRP) associated with opioid agonist pharmacotherapy (OAP) and psychological support, and investigate the modifying effect of patient characteristics, criminal justice system (CJS) referral and treatment completion. DESIGN National data linkage cohort study of the English National Drug Treatment Monitoring System and the Office for National Statistics national mortality database. Data were analysed using survival methods. SETTING All services in England that provide publicly funded, structured treatment for illicit opioid users. PARTICIPANTS Adults treated for opioid dependence during April 2005 to March 2009: 151,983 individuals; 69% male; median age 32.6 with 442,950 person-years of observation. MEASUREMENTS The outcome was fatal DRP occurring during periods in or out of treatment, with adjustment for age, gender, substances used, injecting status and CJS referral. FINDINGS There were 1499 DRP deaths [3.4 per 1000 person-years, 95% confidence interval (CI) = 3.2-3.6]. DRP risk increased while patients were not enrolled in any treatment [adjusted hazard ratio (aHR) = 1.73, 95% CI = 1.55-1.92]. Risk when enrolled only in a psychological intervention was double that during OAP (aHR = 2.07, 95% CI = 1.75-2.46). The increased risk when out of treatment was greater for men (aHR = 1.88, 95% CI = 1.67-2.12), illicit drug injectors (aHR = 2.27, 95% CI = 1.97-2.62) and those reporting problematic alcohol use (aHR = 2.37, 95% CI = 1.90-2.98). CONCLUSIONS Patients who received only psychological support for opioid dependence in England appear to be at greater risk of fatal opioid poisoning than those who received opioid agonist pharmacotherapy.
Collapse
Affiliation(s)
- Matthias Pierce
- Institute of Brain Behaviour and Mental Health, Faculty of Medical and Human SciencesUniversity of ManchesterUK
- Institute of Population Health, Faculty of Medical and Human SciencesUniversity of ManchesterUK
| | | | - Matthew Hickman
- School of Social and Community MedicineUniversity of BristolUK
| | - John Marsden
- Addictions Department, Institute of Psychiatry, Psychology and NeuroscienceKing's College LondonUK
| | - Graham Dunn
- Institute of Population Health, Faculty of Medical and Human SciencesUniversity of ManchesterUK
| | - Andrew Jones
- Institute of Population Health, Faculty of Medical and Human SciencesUniversity of ManchesterUK
| | - Tim Millar
- Institute of Brain Behaviour and Mental Health, Faculty of Medical and Human SciencesUniversity of ManchesterUK
| |
Collapse
|
32
|
Cousins G, Boland F, Courtney B, Barry J, Lyons S, Fahey T. Risk of mortality on and off methadone substitution treatment in primary care: a national cohort study. Addiction 2016; 111:73-82. [PMID: 26234389 DOI: 10.1111/add.13087] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 05/05/2015] [Accepted: 07/30/2015] [Indexed: 11/28/2022]
Abstract
AIM To assess whether risk of death increases during periods of treatment transition, and investigate the impact of supervised methadone consumption on drug-related and all-cause mortality. DESIGN National Irish cohort study. SETTING Primary care. PARTICIPANTS A total of 6983 patients on a national methadone treatment register aged 16-65 years between 2004 and 2010. MEASUREMENT Drug-related (primary outcome) and all-cause (secondary outcome) mortality rates and rate ratios for periods on and off treatment; and the impact of regular supervised methadone consumption. RESULTS Crude drug-related mortality rates were 0.24 per 100 person-years on treatment and 0.39 off treatment, adjusted mortality rate ratio 1.63 [95% confidence interval (CI) = 0.66-4.00]. Crude all-cause mortality rate per 100 person-years was 0.51 on treatment versus 1.57 off treatment, adjusted mortality rate ratio 3.64 (95% CI = 2.11-6.30). All-cause mortality off treatment was 6.36 (95% CI = 2.84-14.22) times higher in the first 2 weeks, 9.12 (95% CI = 3.17-26.28) times higher in weeks 3-4, compared with being 5 weeks or more in treatment. All-cause mortality was lower in those with regular supervision (crude mortality rate 0.60 versus 0.81 per 100 person-years) although, after adjustment, insufficient evidence exists to suggest that regular supervision is protective (mortality rate ratio = 1.23, 95% CI = 0.67-2.27). CONCLUSIONS Among primary care patients undergoing methadone treatment, continuing in methadone treatment is associated with a reduced risk of death. Patients' risk of all-cause mortality increases following treatment cessation, and is highest in the initial 4-week period.
Collapse
Affiliation(s)
- Gráinne Cousins
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fiona Boland
- Health Research Board Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Brenda Courtney
- Health Research Board Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Joseph Barry
- Trinity College Centre for Health Sciences, Tallaght Hospital, Dublin, Ireland
| | | | - Tom Fahey
- Health Research Board Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin, Ireland
| |
Collapse
|
33
|
McAuley A, Aucott L, Matheson C. Exploring the life-saving potential of naloxone: A systematic review and descriptive meta-analysis of take home naloxone (THN) programmes for opioid users. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 26:1183-8. [DOI: 10.1016/j.drugpo.2015.09.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 09/22/2015] [Accepted: 09/23/2015] [Indexed: 10/23/2022]
|
34
|
Eizadi-Mood N, Yaraghi A, Sharifian Z, Feizi A, Hedaiaty M, Sabzghabaee AM. Clinical Presentation and the Outcome of Therapy in a Cohort of Patients with Methadone Toxicity in Iran. Mater Sociomed 2015; 27:276-9. [PMID: 26543423 PMCID: PMC4610605 DOI: 10.5455/msm.2015.27.276-279] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: Agonist maintenance therapy with methadone is amongst the preferred remedies for treating opioid dependence and is increasingly supported by the regional governments in this part of the world. In this study we have investigated the clinical manifestations and factors affecting the outcome of therapy in patients with methadone poisoning in a Middle-Eastern (Iranian) referral tertiary care University hospital. Methods: In this prospective and descriptive-analytic study which was done in a tertiary care and referral University hospital in Iran (2012-2013) all of the admitted patients with a clear and reliable history of methadone poisoning (n=433) were included and demographic data, Clinical status on admission including Glasgow Coma Scale (GCS) score, time elapsed from ingestion to hospital admission, average dose of naloxone used, any history of psychiatric disorder, type of toxic exposure, co ingestion of other medication, hospitalization time and the outcome were recorded and statistically analyzed. Results: The average length of hospital stay was 33 ± 26 hours. 80.1% of patients had ingested methadone alone, and 90.3% survived. Complications were pulmonary edema (7%), aspiration pneumonia (1.4%), generalized tonic colonic seizure (0.9%), and renal failure (0.5%). GCS, systolic blood pressure and respiratory rate were lower in fatal cases and GCS had prognostic value for the outcome of therapy in methadone intoxicated patients. Patients with higher GCS on admission had better outcome [OR =0.47 (95% CI: 0.38-0.580); P value< 0.0001]. Conclusion: Admission time GCS score maybe considered as an important predictor for the outcome of therapy in methadone poisoning.
Collapse
Affiliation(s)
- Nastaran Eizadi-Mood
- Isfahan Clinical Toxicology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ahmad Yaraghi
- Department of Anesthesiology and Critical Care, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zahra Sharifian
- Department of Clinical Toxicology, Noor and Ali-Asghar [PBUH] University hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Awat Feizi
- Department of Biostatistics and Epidemiology, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mahrang Hedaiaty
- Department of Clinical Toxicology, Noor and Ali-Asghar [PBUH] University hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Mohammad Sabzghabaee
- Isfahan Clinical Toxicology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| |
Collapse
|
35
|
Evans E, Kellegan A, Li L, Min J, Huang D, Urada D, Hser YI, Nosyk B. Gender differences in mortality among treated opioid dependent patients. Drug Alcohol Depend 2015; 155:228-35. [PMID: 26282107 PMCID: PMC4581957 DOI: 10.1016/j.drugalcdep.2015.07.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 07/06/2015] [Accepted: 07/07/2015] [Indexed: 02/03/2023]
Abstract
AIMS To assess gender differences in characteristics, mortality rates, and the causes and predictors of death among treated opioid-dependent individuals. METHODS Linked vital statistics data were obtained for all individuals first enrolled in publicly funded pharmacological treatment for opioid dependence in California from 2006 to 2010. Standardized mortality ratios (SMR) were calculated by gender. Cox proportional hazards models with time-varying covariates were fitted to determine the effect of gender on the hazard of all-cause mortality, controlling for covariates. RESULTS Over a median 2.6 years (interquartile range: 1.4-3.7), 1.031 deaths were observed, including 2.2% (259/11,564) of women and 3.7% (772/20,758) of men. Women had a greater increased risk of mortality compared to the general population (SMR 5.1 95% CI: 4.5, 5.7) than men (SMR 4.3 95% CI: 4.0, 4.6). The relative risk of death for women compared with men was 1.18 (95% CI: 1.02, 1.36). Women had a lower instantaneous hazard of all-cause mortality than men (HR 0.58, 95% CI 0.50, 0.68), controlling for other factors. Significant interaction effects indicated that among men, mortality risk was decreased by full-time employment and increased by non-daily heroin use (relative to daily use) and medical problems. Concurrent opioid and methamphetamine/cocaine use increased mortality risk among women and decreased it among men. CONCLUSIONS Treatment for opioid dependence is likely to reduce mortality risk among men by addressing employment and medical problems, and via interventions to reduce overdose risk after heroin abstinence, and among women by attending to the concurrent use of methamphetamine/cocaine and opioids.
Collapse
Affiliation(s)
- E Evans
- UCLA Integrated Substance Abuse Programs, United States.
| | - A Kellegan
- UCLA Integrated Substance Abuse Programs
| | - L Li
- UCLA Integrated Substance Abuse Programs
| | - J Min
- British Columbia Centre for Excellence in HIV/AIDS
| | - D Huang
- UCLA Integrated Substance Abuse Programs
| | - D Urada
- UCLA Integrated Substance Abuse Programs
| | - YI Hser
- UCLA Integrated Substance Abuse Programs
| | - B Nosyk
- British Columbia Centre for Excellence in HIV/AIDS,Simon Fraser University, Faculty of Health Sciences
| |
Collapse
|
36
|
Leece P, Cavacuiti C, Macdonald EM, Gomes T, Kahan M, Srivastava A, Steele L, Luo J, Mamdani MM, Juurlink DN. Predictors of Opioid-Related Death During Methadone Therapy. J Subst Abuse Treat 2015; 57:30-5. [DOI: 10.1016/j.jsat.2015.04.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 03/23/2015] [Accepted: 04/12/2015] [Indexed: 01/18/2023]
|
37
|
Palmaro A, Dupouy J, Lapeyre-Mestre M. Benzodiazepines and risk of death: Results from two large cohort studies in France and UK. Eur Neuropsychopharmacol 2015; 25:1566-77. [PMID: 26256008 DOI: 10.1016/j.euroneuro.2015.07.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 06/01/2015] [Accepted: 07/14/2015] [Indexed: 10/23/2022]
Abstract
Benzodiazepines are widely prescribed for the treatment of anxiety or insomnia, but their impact on mortality is still debated. This study investigated the impact of benzodiazepine use on short term mortality. Exposed-unexposed cohorts were constructed with the Clinical Practice Research Datalink (CPRD) in the UK and with the General Sample of Beneficiaries (EGB) in France. Benzodiazepine incident users were matched to incident users of antidepressants/non-benzodiazepine sedatives and to controls (non-users of antidepressants or anxiolytics/hypnotics) according to age and gender in both sources (and practice for the CPRD only). Survival at one year was studied using Cox regression model. In the CPRD, the final population comprised 94 123 patients per group (57 287 in the EGB). In the CPRD, adjusted HR was 3.73 in benzodiazepine users (95% CI, 3.43-4.06), and 1.61 (1.47-1.76) in antidepressant/non-benzodiazepine users compared to controls. When considering benzodiazepine use as a time-dependent covariate, adjusted HR for current use at 12 months was 1.70 (1.36-2.12). In the EGB, adjusted HR was 1.26 in benzodiazepine users (95% CI, 1.08-1.48), and 1.07 (95% CI, 0.91-1.27) in antidepressant/non-benzodiazepine users. When considering benzodiazepine use as a time-dependent covariate, adjusted HR for current use at 12 months was 1.03 (0.74-1.44). Using two nationally representative databases, we found a significant while moderate increase in all-cause mortality in relation to benzodiazepines, in a population of incident and mostly occasional users. This issue need to be monitored given the extensive use of these drugs.
Collapse
Affiliation(s)
- Aurore Palmaro
- UMR Inserm 1027, Université Toulouse III, 37, allées Jules Guesde, 31073 Toulouse cedex, France; Service de Pharmacologie Clinique, CHU Toulouse, 37, allées Jules Guesde, 31073 Toulouse cedex, France.
| | - Julie Dupouy
- UMR Inserm 1027, Université Toulouse III, 37, allées Jules Guesde, 31073 Toulouse cedex, France
| | - Maryse Lapeyre-Mestre
- UMR Inserm 1027, Université Toulouse III, 37, allées Jules Guesde, 31073 Toulouse cedex, France; Service de Pharmacologie Clinique, CHU Toulouse, 37, allées Jules Guesde, 31073 Toulouse cedex, France
| |
Collapse
|
38
|
Kimber J, Larney S, Hickman M, Randall D, Degenhardt L. Mortality risk of opioid substitution therapy with methadone versus buprenorphine: a retrospective cohort study. Lancet Psychiatry 2015; 2:901-8. [PMID: 26384619 DOI: 10.1016/s2215-0366(15)00366-1] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 07/14/2015] [Accepted: 07/29/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Opioid dependence increases risk of premature mortality. Opioid substitution therapy with methadone or buprenorphine reduces mortality risk, especially for drug-related overdose. Clinical guidelines recommend methadone as the first line of opioid substitution therapy. We aimed to test whether buprenorphine treatment has a lower mortality risk than does methadone treatment by comparing all-cause mortality and drug-related overdose mortality at treatment induction, after in-treatment medication switches, and following treatment cessation. METHODS We did a retrospective cohort study of all patients with opioid dependency (n=32,033) in New South Wales, Australia, who started a methadone or buprenorphine treatment episode from Aug 1, 2001, to Dec 31, 2010, including 190,232·6 person-years of follow-up. We compared crude mortality rates (CMRs) for all-cause and drug-related overdose mortality, and mortality rate ratios (MRRs) according to age, sex, period in or out of treatment, medication type, and in-treatment switching. FINDINGS Patients who initiated with buprenorphine had reduced all-cause and drug-related mortality during the first 4 weeks of treatment compared with those who initiated with methadone (adjusted all-cause MRR 2·17, 95% CI 1·29-3·67; adjusted drug-related MRR 4·88, 1·73-13·69). For the remaining time on treatment, drug-related mortality risk did not differ (adjusted MRR 1·18, 95% CI 0·89-1·56), but weak evidence suggested that all-cause mortality was lower for buprenorphine than methadone (1·66, 1·40-1·96). In the 4 weeks after treatment cessation, all-cause mortality did not differ, but drug-related mortality was lower for methadone (adjusted all-cause MRR 1·12, 0·79-1·59; adjusted drug-related MRR 0·50, 0·29-0·86). Patients who switched from buprenorphine to methadone during treatment had lower mortality in the first 4 weeks of methadone treatment than matched controls who received methadone only (CMR difference 7·1 per 1000 person-years, 95% CI 0·1-14·0); no mortality difference was noted for switches from buprenorphine to methadone or for switches to either medication beyond the first 4 weeks of treatment. INTERPRETATION In a setting with high risk of death in the first 4 weeks of opioid substitution therapy, buprenorphine seemed to reduce mortality in this period, but little difference between buprenorphine and methadone was noted thereafter or for in-treatment switching of medications. Cross-cohort corroboration of our findings and further assessment of the stepped treatment model is warranted. FUNDING Australian National Health & Medical Research Council.
Collapse
Affiliation(s)
- Jo Kimber
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia; Addictions Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.
| | - Sarah Larney
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia; Alpert Medical School, Brown University, Providence, RI, USA
| | - Matthew Hickman
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Deborah Randall
- Centre for Big Data Research, University of New South Wales, Sydney, NSW, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia; School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| |
Collapse
|
39
|
Hassanian-Moghaddam H, Soltaninejad K, Shadnia S, Kabir A, Movahedi M, Mirafzal A. Risk Factors for Mortality and Endotracheal Intubation after Methadone Intoxication. Basic Clin Pharmacol Toxicol 2015; 118:231-7. [PMID: 26301535 DOI: 10.1111/bcpt.12476] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 08/13/2015] [Indexed: 11/29/2022]
Abstract
This was a retrospective chart review to evaluate various risk factors associated with in-hospital mortality and intubation risk in acute methadone overdose. All patients admitted to an academic hospital in Tehran, Iran, during a 10-year period (2000-2009) constituted the study sample. Exclusion criteria were significant comorbidities and age under 18 years. Outcome variables were in-hospital mortality and being intubated during admission. A total of 802 patients were enrolled in the study. There were 15 (1.8%) deaths due to methadone overdose or its complications. The number of yearly admissions was 15 patients in 2000, 16 in 2001, 16 in 2002, 18 in 2003, 23 in 2004, 38 in 2005, 59 in 2006, 110 in 2007, 206 in 2008 and 301 in 2009. Based on logistic regression analysis, the most important independent variable predicting mortality was length of admission in toxicology ward [OR (95% CI): 1.6 (1.1-2.3)]. For the prediction of intubation, independent variables were Glasgow Coma Scale (GCS) score of 5-9 [OR (95% CI): 356.5 (9.8-12907.4)] in the emergency department (ED), miosis in the ED [356.9 (1.4-87872.5)] and respiratory rate in the ED [1.5 (1.1-2.1)]. Linear regression model for length of hospitalization showed patient age as the most important variable for prediction of this outcome. Despite a relatively low mortality rate, the increasing number of methadone-poisoned patients requires special attention to this common intoxication. Careful disposition of patients from ED to ordinary wards or intensive care units and also from higher to lower levels of care should be considered in methadone overdose.
Collapse
Affiliation(s)
- Hossein Hassanian-Moghaddam
- Department of Clinical Toxicology, Loghman-Hakim Hospital, School of Medicine, Shahid-Beheshti University of Medical Sciences, Tehran, Iran.,Excellence Center of Clinical Toxicology, Iranian Ministry of Health, Tehran, Iran
| | - Kambiz Soltaninejad
- Department of Forensic Toxicology, Legal Medicine Research Center, Legal Medicine Organization of Iran, Tehran, Iran
| | - Shahin Shadnia
- Department of Clinical Toxicology, Loghman-Hakim Hospital, School of Medicine, Shahid-Beheshti University of Medical Sciences, Tehran, Iran.,Excellence Center of Clinical Toxicology, Iranian Ministry of Health, Tehran, Iran
| | - Ali Kabir
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran.,Department of Epidemiology, School of Public Health, Shahid-Beheshti University of Medical Sciences, Tehran, Iran
| | - Mitra Movahedi
- Department of Emergency Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Amirhossein Mirafzal
- Department of Emergency Medicine, Kerman University of Medical Sciences, Kerman, Iran
| |
Collapse
|
40
|
Blom B, Dukes KA, Lundgren L, Sullivan LM. Register data in the evaluation and program planning of addiction treatment programs: using Sweden as an example. EVALUATION AND PROGRAM PLANNING 2015; 49:185-191. [PMID: 25577662 DOI: 10.1016/j.evalprogplan.2014.12.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Data from large-scale registers is often underutilized when evaluating addiction treatment programs. Since many programs collect register data regarding clients and interventions, there is a potential to make greater use of such records for program evaluation. The purpose of this article is to discuss the value of using large-scale registers in the evaluation and program planning of addiction treatment systems and programs. Sweden is used as an example of a country where register data is both available and is starting to be used in national evaluation and program planning efforts. The article focuses on possibilities, limitations and practicalities when using large-scale register data to conduct evaluations and program planning of addiction treatment programs. Main conclusions are that using register data for evaluation provides large amounts of data at low cost, limitations associated to the use of register data may be handled statistically, register data can answer important questions in planning of addiction treatment programs, and more accurate measures are needed to account for the diversity of client populations.
Collapse
Affiliation(s)
- Björn Blom
- Department of Social Work, Umeå University, SE-901 87 Umeå, Sweden.
| | - Kimberly A Dukes
- DM-STAT, One Salem Street Suite 300, Malden, MA 02148 USA; Department of Biostatistics, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118 USA
| | - Lena Lundgren
- Department of Social Work, Umeå University, SE-901 87 Umeå, Sweden; Center for Addictions Research and Services, Boston University School of Social Work, 264 Bay State Road, Boston, MA 02215 USA
| | - Lisa M Sullivan
- Department of Biostatistics, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118 USA
| |
Collapse
|
41
|
Weimer MB, Chou R. Research gaps on methadone harms and comparative harms: findings from a review of the evidence for an American Pain Society and College on Problems of Drug Dependence clinical practice guideline. THE JOURNAL OF PAIN 2014; 15:366-76. [PMID: 24685460 DOI: 10.1016/j.jpain.2014.01.496] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 01/21/2014] [Accepted: 01/21/2014] [Indexed: 01/10/2023]
Abstract
UNLABELLED Methadone-associated overdose deaths have dramatically increased. In order to inform an evidence-based clinical practice guideline to improve safety of methadone prescribing, the American Pain Society commissioned a systematic review on various aspects related to methadone safety. We searched Ovid MEDLINE, Cochrane Library, and PsycINFO databases through July 2012 to identify studies that addressed 1 or more of 17 Key Questions related to methadone safety; an update search was performed in 2014 for new studies related to methadone-related overdose and risks related to cardiac arrhythmias. A total of 168 studies met inclusion criteria for the review. The purpose of this article is to highlight critical research gaps in the literature related to methadone safety. These include lack of evidence on risk factors associated with methadone-overdose deaths and adverse events, limited evidence to evaluate the comparative mortality of methadone versus other opioids, insufficient evidence to fully understand the harms associated with methadone use during pregnancy, and insufficient evidence to determine effects of risk mitigation strategies such as electrocardiogram monitoring, strategies for managing patients with prolonged QTc intervals on screening, urine drug testing, alternative dosing regimens for initiation and titration of therapy, and timing of follow-up. Therefore, most guideline recommendations are based on weak evidence. More research is needed to guide safe methadone prescribing practices and decrease the adverse events associated with methadone. PERSPECTIVE This article summarizes critical research gaps in the literature related to methadone safety, based on a systematic review commissioned by the American Pain Society. Critical research gaps were identified in a number of areas, highlighting the need for additional research to guide safer prescribing and risk mitigation strategies.
Collapse
Affiliation(s)
- Melissa B Weimer
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Roger Chou
- Department of Medicine, Oregon Health & Science University, Portland, Oregon; Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon; Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon.
| |
Collapse
|
42
|
Chou R, Cruciani RA, Fiellin DA, Compton P, Farrar JT, Haigney MC, Inturrisi C, Knight JR, Otis-Green S, Marcus SM, Mehta D, Meyer MC, Portenoy R, Savage S, Strain E, Walsh S, Zeltzer L. Methadone safety: a clinical practice guideline from the American Pain Society and College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society. THE JOURNAL OF PAIN 2014; 15:321-37. [PMID: 24685458 DOI: 10.1016/j.jpain.2014.01.494] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 01/21/2014] [Accepted: 01/21/2014] [Indexed: 01/08/2023]
Abstract
UNLABELLED Methadone is used for the treatment of opioid addiction and for treatment of chronic pain. The safety of methadone has been called into question by data indicating a large increase in the number of methadone-associated overdose deaths in recent years that has occurred in parallel with a dramatic rise in the use of methadone for chronic pain. The American Pain Society and the College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society, commissioned an interdisciplinary expert panel to develop a clinical practice guideline on safer prescribing of methadone for treatment of opioid addiction and chronic pain. As part of the guideline development process, the American Pain Society commissioned a systematic review of various aspects related to safety of methadone. After a review of the available evidence, the expert panel concluded that measures can be taken to promote safer use of methadone. Specific recommendations include the need to educate and counsel patients on methadone safety, use of electrocardiography to identify persons at greater risk for methadone-associated arrhythmia, use of alternative opioids in patients at high risk of complications related to corrected electrocardiographic QTc interval prolongation, careful dose initiation and titration of methadone, and diligent monitoring and follow-up. Although these guidelines are based on a systematic review, the panel identified numerous research gaps, most recommendations were based on low-quality evidence, and no recommendations were based on high-quality evidence. PERSPECTIVE This guideline, based on a systematic review of the evidence on methadone safety, provides recommendations developed by a multidisciplinary expert panel. Safe use of methadone requires clinical skills and knowledge in use of methadone to mitigate potential risks, including serious risks related to risk of overdose and cardiac arrhythmias.
Collapse
Affiliation(s)
- Roger Chou
- Departments of Medicine and Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, and Pacific Northwest Evidence-based Practice Center, Portland, Oregon.
| | - Ricardo A Cruciani
- Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, New York
| | - David A Fiellin
- School of Public Health, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - John T Farrar
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark C Haigney
- Cardiology Uniformed Services, University of the Health Sciences, Baltimore, Maryland
| | - Charles Inturrisi
- Department of Pharmacology, Weill Cornell Medical College, New York, New York
| | - John R Knight
- Center for Adolescent Substance Abuse Research, Children's Hospital Boston, Boston, Massachusetts
| | - Shirley Otis-Green
- Division of Nursing Research and Education, Department of Population Sciences, City of Hope National Medical Center, Duarte, California
| | - Steven M Marcus
- School of Biomedical and Health Sciences, New Jersey Medical School, Rutgers University, Newark, New Jersey
| | - Davendra Mehta
- Departments of Medicine and Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marjorie C Meyer
- Departments of Gynecology and Maternal Fetal Medicine, University of Vermont, Burlington, Vermont
| | - Russell Portenoy
- Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, New York
| | - Seddon Savage
- Department of Anesthesiology, Dartmouth Medical School, Hanover, New Hampshire
| | - Eric Strain
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sharon Walsh
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Lonnie Zeltzer
- Pediatric Pain Program, Mattel Children's Hospital at UCLA, Los Angeles, California
| | | | | |
Collapse
|
43
|
Chou R, Weimer MB, Dana T. Methadone overdose and cardiac arrhythmia potential: findings from a review of the evidence for an American Pain Society and College on Problems of Drug Dependence clinical practice guideline. THE JOURNAL OF PAIN 2014; 15:338-65. [PMID: 24685459 DOI: 10.1016/j.jpain.2014.01.495] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 01/21/2014] [Accepted: 01/21/2014] [Indexed: 12/01/2022]
Abstract
UNLABELLED The number of deaths associated with methadone use increased dramatically in parallel with marked increases in its use, particularly for treatment of chronic pain. To develop a clinical guideline on methadone prescribing to reduce potential harms, the American Pain Society commissioned a review of various aspects related to methadone safety. This article summarizes evidence related to unintentional overdose due to methadone and harms related to cardiac arrhythmia potential. We searched Ovid MEDLINE, the Cochrane Library, and PsycINFO databases through January 2014 for studies assessing harms associated with methadone use; we judged 70 studies to be relevant and to meet inclusion criteria. The majority of studies on overdose and cardiac arrhythmia risk are observational and provide weak evidence on which to base clinical guidelines. In patients prescribed methadone for treatment of opioid dependence, data suggest that mortality benefits related to reduction in illicit drug use outweigh harms. Despite epidemiologic data showing marked increases in the numbers of methadone-related deaths that have been primarily attributed to increased use of methadone for chronic pain, evidence on methadone and mortality risk in this population has been somewhat contradictory. There is some evidence that recent initiation of methadone, psychiatric admissions, and concomitant use of benzodiazepines are associated with a higher risk for overdose. Evidence on cardiac risks is primarily limited to case reports of torsades de pointes, primarily in patients on high doses of methadone, and to studies showing an association between methadone use and prolongation of QTc intervals. Research is needed to understand the effectiveness of dosing methods, electrocardiogram monitoring, and other risk mitigation strategies in patients prescribed methadone. PERSPECTIVE This systematic review synthesizes the evidence related to methadone use and risk for overdose and cardiac arrhythmia. Findings regarding the association between methadone use and QTc interval prolongation and risk factors for methadone-associated overdose suggest potential targets for risk mitigation strategies, though research is needed to determine the effectiveness of such strategies at reducing adverse outcomes.
Collapse
Affiliation(s)
- Roger Chou
- Department of Medicine, Oregon Health & Science University, Portland, Oregon; Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon; Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon.
| | - Melissa B Weimer
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Tracy Dana
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon
| |
Collapse
|
44
|
Carrieri PM, Michel L, Lions C, Cohen J, Vray M, Mora M, Marcellin F, Spire B, Morel A, Roux P. Methadone induction in primary care for opioid dependence: a pragmatic randomized trial (ANRS Methaville). PLoS One 2014; 9:e112328. [PMID: 25393311 PMCID: PMC4231094 DOI: 10.1371/journal.pone.0112328] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 09/29/2014] [Indexed: 11/17/2022] Open
Abstract
Objective Methadone coverage is poor in many countries due in part to methadone induction being possible only in specialized care (SC). This multicenter pragmatic trial compared the effectiveness of methadone treatment between two induction models: primary care (PC) and SC. Methods In this study, registered at ClinicalTrials.Gov (NCT00657397), opioid-dependent individuals not on methadone treatment for at least one month or receiving buprenorphine but needing to switch were randomly assigned to start methadone in PC (N = 155) or in SC (N = 66) in 10 sites in France. Visits were scheduled at months M0, M3, M6 and M12. The primary outcome was self-reported abstinence from street-opioids at 12 months (M12) (with an underlying 15% non-inferiority hypothesis for PC). Secondary outcomes were abstinence during follow-up, engagement in treatment (i.e. completing the induction period), retention and satisfaction with the explanations provided by the physician. Primary analysis used intention to treat (ITT). Mixed models and the log-rank test were used to assess the arm effect (PC vs. SC) on the course of abstinence and retention, respectively. Results In the ITT analysis (n = 155 in PC, 66 in SC), which compared the proportions of street-opioid abstinent participants, 85/155 (55%) and 22/66 (33%) of the participants were classified as street-opioid abstinent at M12 in PC and SC, respectively. This ITT analysis showed the non-inferiority of PC (21.5 [7.7; 35.3]). Engagement in treatment and satisfaction with the explanations provided by the physician were significantly higher in PC than SC. Retention in methadone and abstinence during follow-up were comparable in both arms (p = 0.47, p = 0.39, respectively). Conclusions Under appropriate conditions, methadone induction in primary care is feasible and acceptable to both physicians and patients. It is as effective as induction in specialized care in reducing street-opioid use and ensuring engagement and retention in treatment for opioid dependence. Trial registration Number Eudract 2008-001338-28; ClinicalTrials.gov: NCT00657397; International Standard Randomized Controlled Trial Number Register ISRCTN31125511
Collapse
Affiliation(s)
- Patrizia Maria Carrieri
- INSERM UMR912 (SESSTIM), Marseille, France; Aix Marseille Université, UMR_S912, Marseille, France; ORS PACA, Observatoire Régional de la Santé Provence Alpes Côte d'Azur, Marseille, France
| | - Laurent Michel
- INSERM, Research Unit 669, Paris, France; Univ Paris-Sud and Univ Paris Descartes, UMR-S0669, Paris, France; Centre Pierre Nicole, Paris, France
| | - Caroline Lions
- INSERM UMR912 (SESSTIM), Marseille, France; Aix Marseille Université, UMR_S912, Marseille, France; ORS PACA, Observatoire Régional de la Santé Provence Alpes Côte d'Azur, Marseille, France
| | - Julien Cohen
- INSERM UMR912 (SESSTIM), Marseille, France; Aix Marseille Université, UMR_S912, Marseille, France; ORS PACA, Observatoire Régional de la Santé Provence Alpes Côte d'Azur, Marseille, France
| | - Muriel Vray
- Unité de Recherche et d'Expertise en Epidémiologie des Maladies Emergentes, Institut Pasteur, Paris, France; Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France
| | - Marion Mora
- INSERM UMR912 (SESSTIM), Marseille, France; Aix Marseille Université, UMR_S912, Marseille, France; ORS PACA, Observatoire Régional de la Santé Provence Alpes Côte d'Azur, Marseille, France
| | - Fabienne Marcellin
- INSERM UMR912 (SESSTIM), Marseille, France; Aix Marseille Université, UMR_S912, Marseille, France; ORS PACA, Observatoire Régional de la Santé Provence Alpes Côte d'Azur, Marseille, France
| | - Bruno Spire
- INSERM UMR912 (SESSTIM), Marseille, France; Aix Marseille Université, UMR_S912, Marseille, France; ORS PACA, Observatoire Régional de la Santé Provence Alpes Côte d'Azur, Marseille, France
| | | | - Perrine Roux
- INSERM UMR912 (SESSTIM), Marseille, France; Aix Marseille Université, UMR_S912, Marseille, France; ORS PACA, Observatoire Régional de la Santé Provence Alpes Côte d'Azur, Marseille, France
| | | |
Collapse
|
45
|
Taheri F, Yaraghi A, Sabzghabaee AM, Moudi M, Eizadi-Mood N, Gheshlaghi F, Farajzadegan Z. Methadone toxicity in a poisoning referral center. J Res Pharm Pract 2014; 2:130-4. [PMID: 24991620 PMCID: PMC4076914 DOI: 10.4103/2279-042x.122387] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective: Methadone poisoning can occur accidentally or intentionally for suicide or homicide purposes. The aim of this study was to evaluate the epidemiological and clinical manifestations of Methadone poisoning. Methods: A descriptive analytical study was performed from 2010 to 2012 in the poisoning emergency and clinical toxicology departments of Noor hospital affiliated with Isfahan University of Medical Sciences (Isfahan, Iran). All patients with Methadone poisoning within this period of time were investigated. Different variables were recorded in a checklist. Findings: A total of 385 patients were studied. About 85.7% had ingested only Methadone and 14.3% had ingested other medications with Methadone. Mean ± standard deviation of the age was 32.1 ± 15 years (range: 1-90). Most of the patients were male (76.4%). Nearly 40% of the patients were narcotic addicts, 25.5% were addicts under surveillance of Methadone maintenance therapy centers and 34.5% were non-addicts. Intentional poisoning was observed in most of the patients (57.7%). Most of the patients had a low level of consciousness on admission (58.2%). Respiratory depression and hypotension was observed in 35.6% and 12.7% of the cases as the most common symptoms. Regarding vital signs, there was a significant difference in respiratory rate on admission among different evaluated groups (P = 0.02). Length of hospital stay was 18.79 ± 0.72 h (range: 4-240 h, median: 15 h). About 57 patients (25.8%) from the intentionally poisoned patients and 19 patients (12.3%) from the unintentionally poisoned patients had a history of psychiatric disorder (P = 0.001). Most of the patients survived without complications. Conclusion: Addiction, age, gender, attempt to suicide and a history of psychiatric disorder were of the most important factors effective in Methadone poisoning, which should be considered in the public training and prevention of poisoning.
Collapse
Affiliation(s)
- Fatemeh Taheri
- Isfahan Clinical Toxicology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ahmad Yaraghi
- Isfahan Clinical Toxicology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Mohammad Sabzghabaee
- Isfahan Clinical Toxicology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Maryam Moudi
- Department of Biology, University of Putra Malaysia, Malaysia
| | - Nastaran Eizadi-Mood
- Isfahan Clinical Toxicology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Farzad Gheshlaghi
- Isfahan Clinical Toxicology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ziba Farajzadegan
- Department of Health and Social Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| |
Collapse
|
46
|
Park TW, Bohnert AS, Austin KL, Saitz R, Pizer SD. Datapoints: regional variation in benzodiazepine prescribing for patients on opioid agonist therapy. Psychiatr Serv 2014; 65:4. [PMID: 24382761 PMCID: PMC5697151 DOI: 10.1176/appi.ps.650308] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
47
|
Cao X, Wu Z, Li L, Pang L, Rou K, Wang C, Luo W, Yin W, Li J, McGoogan JM. Mortality among methadone maintenance clients in China: a six-year cohort study. PLoS One 2013; 8:e82476. [PMID: 24349294 PMCID: PMC3861403 DOI: 10.1371/journal.pone.0082476] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Accepted: 11/02/2013] [Indexed: 11/24/2022] Open
Abstract
Objective To assess the overall mortality of methadone maintenance treatment (MMT) clients in China and its associated factors. Methods A total of 1,511 MMT clients, all of whom enrolled in China's first eight MMT clinics between March and December 2004, were included in this cohort study and followed for approximately six years, until June 2010. Mortality and its predictors were examined using Cox proportional hazards regression models. Results A total of 154 deaths were observed within 5,391 person-years (PY) of follow-up for an all-cause mortality rate of 28.6 per 1,000 PY. The leading causes of death were drug overdose (33.8%), HIV/AIDS-unrelated disease (21.4%), and HIV/AIDS (16.9%). The all-cause mortality rate of clients engaged in MMT for one year or less was roughly three times that of clients who stayed in MMT for four years or more (14.0 vs. 4.6, p<0.0001), HIV-positive subjects was nearly four times mortality rate than that of HIV-negative individuals (28.1 vs.6.8, p<0.0001). ART-naive HIV-positive subjects had approximately two times higher mortality rate than those receiving ART (31.2 vs. 17.3, <0.0001). After adjusting for confounding variables, we found that being male (HR = 1.63, CI: 1.03–2.57, p = 0.0355) and being HIV-positive (HR = 5.16, CI: 3.70–7.10, p<0.0001) were both associated with higher risk of death whereas increased durations of methadone treatment were associated with a lower risk of death (HR = 0.26, CI: 0.18–0.38, p<0.0001 for two to three years, HR = 0.08, CI: 0.05–0.14, p<0.0001 for four or more years). Conclusion Overall mortality was high among MMT clients in China. Specific interventions aimed at decreasing mortality among MMT clients are needed. Our study supports the need for keeping client at MMT longer and for expanding ART coverage and suggests the potential benefits of integrated MMT and ART services for drug users in China.
Collapse
Affiliation(s)
- Xiaobin Cao
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Zunyou Wu
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
- * E-mail:
| | - Li Li
- Semel Institute Center for Community Health, University of California Los Angeles, Los Angeles, California, United States of America
| | - Lin Pang
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Keming Rou
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Changhe Wang
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Wei Luo
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Wenyuan Yin
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Jianhua Li
- Yunnan Institute of Drug Abuse, Kunming, Yunnan, China
| | - Jennifer M. McGoogan
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | | |
Collapse
|
48
|
Vogel M, Knöpfli B, Schmid O, Prica M, Strasser J, Prieto L, Wiesbeck GA, Dürsteler-MacFarland KM. Treatment or "high": benzodiazepine use in patients on injectable heroin or oral opioids. Addict Behav 2013; 38:2477-84. [PMID: 23770646 DOI: 10.1016/j.addbeh.2013.05.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 03/27/2013] [Accepted: 05/07/2013] [Indexed: 12/26/2022]
Abstract
Benzodiazepine (BZD) use is widespread among opioid-maintained patients worldwide. We conducted a cross-sectional survey to investigate motives and patterns of BZD use and psychiatric comorbidity in a convenience sample of patients (n=193) maintained on oral opioid agonists or diacetylmorphine (DAM). Prolonged BZD use and high-risk behaviors like parenteral use were common. After principal component analysis, motives were divided into those related to negative affect regulation, positive affect regulation (i.e. reward-seeking) and somato-medical problems. Negative affect regulation and somato-medical motives were associated with prolonged use. Psychiatric comorbidity was associated with several self-therapeutic motives, most importantly to lose anxiety. Patients maintained on DAM were more likely to be ex-users of BZD and report high positive affect regulation. Therefore, patients maintained on different agonists may have deviating motives for BZD use, which could be of importance when addressing this issue. Treatment of psychiatric comorbidity, in particular anxiety, depressive and sleeping disorders, may be helpful in reducing BZD use, particularly in patients maintained on oral opioids.
Collapse
|
49
|
Liao DL, Chen PC, Chen CH, Hsieh CJ, Huang YF, Shih WY, Cheng JJS. Higher methadone doses are associated with lower mortality in patients of opioid dependence in Taiwan. J Psychiatr Res 2013; 47:1530-4. [PMID: 23880602 DOI: 10.1016/j.jpsychires.2013.07.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Revised: 06/02/2013] [Accepted: 07/01/2013] [Indexed: 01/18/2023]
Abstract
Optimal methadone dosage and service profile is challenging in treatment of opioid dependence. This study explores the impact of methadone dosage on the mortality of opioid-dependent patients in methadone maintenance therapy by using a large-scale and continual supervised dosing registry information system. Database of nationwide enrolled opioid-dependent patients at methadone clinics in Taiwan during 2006-2008 was assessed. The relative risk of age, sex, marital status, HIV infection and methadone dosage were analyzed by Cox regression analysis. Among all of the 33,549 recruited patients, the crude mortality rate was 134.78/10,000 person-years, and the standardized mortality ratio was 4.68. A dose-response relationship of higher- vs. lower-dosage groups on the risk of mortality risk was observed (adjusted HR = 0.68, P = 0.016). In further sub-grouping analysis, this trend was more significant in HIV positive patients, in subgroup of patients who continuously staying in MMT, and in subgroup of patients who re-enter MMT. This dosage effect is not significantly seen in patients receiving MMT more than 365 days. Further exploration of other treatment-related factors may be important for understanding the long-term treatment outcome of opioid addiction patients.
Collapse
Affiliation(s)
- Ding-Lieh Liao
- Department of Addiction Psychiatry, Bali Psychiatric Center, Taiwan
| | | | | | | | | | | | | |
Collapse
|
50
|
Lloyd B, Barratt MJ, Ferris J, Best D, Lubman DI. Factors influencing mortality among alcohol and drug treatment clients in Victoria, Australia: the role of demographic and substance use characteristics. Aust N Z J Psychiatry 2013; 47:859-67. [PMID: 23719182 DOI: 10.1177/0004867413491155] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Clinical studies consistently identify alcohol- and drug-related treatment populations as more likely to die prematurely compared with an age-matched general population. However, demographic characteristics and primary drug of concern as predictors of mortality risk following treatment have not been adequately explored. This paper examines relationships between substance use, demographic factors and mortality among alcohol and drug treatment clients. METHOD A retrospective cohort incorporating 7 years of data was utilised to examine mortality outcomes in the 2 years following treatment among Victorian clients recorded on the Alcohol and Drug Information Service (ADIS) database by linking partial client identifiers with the National Death Index (NDI). A cohort of 18,686 clients engaged in at least one course of treatment over a 12-month period was included. Analysis was of crude and standardised mortality rates across client groups in terms of the presenting drug of concern for treatment and demographic characteristics. RESULTS A higher risk of premature death was associated with older age, being male, not being employed, living alone, medical and psychiatric comorbidity, recent injecting, and a history of intensive drug treatment access. Alcohol treatment clients had the worst prognosis. After adjustment for client characteristics, alcohol treatment clients experienced a significantly higher rate of death compared with other clients. CONCLUSIONS Findings from these previously unexplored data highlight the need to increase awareness of the range and magnitude of risks associated with harmful alcohol use, and to identify approaches to enhance treatment effectiveness to reduce negative outcomes following treatment for populations at elevated risk of harm.
Collapse
Affiliation(s)
- Belinda Lloyd
- Turning Point Alcohol & Drug Centre, Eastern Health, Melbourne, Australia.
| | | | | | | | | |
Collapse
|