Impact of supervision of methadone consumption on deaths related to methadone overdose (1993-2008): analyses using OD4 index in England and Scotland

Time for Australia to increase take away doses in opioid agonist treatment

Opioid Agonist Treatment is the cornerstone of minimising harms related to opioid use, however its uptake is limited by a tightly regulated and stigmatising treatment environment. The COVID-19 pandemic necessitated relaxation of some treatment restrictions, with global evidence pointing to more patient-centred care in this time. In light of local evidence to support the safety of increased access to takeaway doses and a precedent set by the Substance Abuse and Mental Health Administration, we recommend adoption of the Australian Interim Medication Assisted Treatment of Opioid Dependence guidance in Australia.

Managing Opioid Withdrawal Symptoms During the Fentanyl Crisis: A Review

Illicitly manufactured fentanyl (IMF) is a significant contributor to the increasing rates of overdose-related deaths. Its high potency and lipophilicity can complicate opioid withdrawal syndromes (OWS) and the subsequent management of opioid use disorder (OUD). This scoping review aimed to collate the current OWS management of study populations seeking treatment for OWS and/or OUD directly from an unregulated opioid supply, such as IMF. Therefore, the focus was on therapeutic interventions published between January 2010 and November 2023, overlapping with the period of increasing IMF exposure. A health science librarian conducted a systematic search on November 13, 2023. A total of 426 studies were screened, and 173 studies were reviewed at the full-text level. Forty-nine studies met the inclusion criteria. Buprenorphine and naltrexone were included in most studies with the goal of transitioning to a long-acting injectable version. Various augmenting agents were tested (buspirone, memantine, suvorexant, gabapentin, and pregabalin); however, the liberal use of adjunctive medication and shortened timelines to initiation had the most consistently positive results. Outside of FDA-approved medications for OUD, lofexidine, gabapentin, and suvorexant have limited evidence for augmenting opioid agonist initiation. Trials often have low retention rates, particularly when opioid agonist washout is required. Neurostimulation strategies were promising; however, they were developed and studied early. Precipitated withdrawal is a concern; however, the rates were low and adequately mitigated or managed with low- or high-dose buprenorphine induction. Maintenance treatment continues to be superior to detoxification without continued management. Shorter induction protocols allow patients to initiate evidence-based treatment more quickly, reducing the use of illicit or non-prescribed substances.

Understanding and learning from rural drug service adaptations to opioid substitution therapy during the COVID-19 pandemic: the What C-OST? study

Introduction

In April 2020, in response to government COVID-19 advice, changes were made to the way English drug services operated. Methadone and buprenorphine were typically dispensed in 1- to 2-week supplies, and key working was conducted by phone/online. Previous studies have examined the impact of these changes on people from urban settings. This study adds the experiences and perspectives of people receiving care from drug services in rural areas and makes suggestions for future emergency planning.

Methods

Telephone semi-structured interviews were conducted with 15 people receiving care in Somerset, Wiltshire, and Suffolk, rural counties in England. Reflexive thematic analysis was used.

Results

Three overarching themes were found. "Challenges of rural lockdown" (theme 1) describes how rural community challenges, especially reduced or no rural public transport, were experienced. This hampered some OST collections, with consequential drug use. It also impeded connections to loved ones, worsening isolation. For participants who were struggling pre-pandemic, the intersection between this and their experience of revised drug service operations is embodied in "Amplification of Social Disconnection: Cut off and unheard" (theme 2). They felt a lack of support, particularly from remote provision key working. Participants who had supportive relationships and time in the pandemic occupied in ways they found meaningful, and others who struggled with anxiety or depression, found pandemic changes "Fits better with my life" (theme 3). They experienced more freedom for other things, gained support by other means, such as family, or felt more comfortable with remote engagement. A cross-cutting sub-theme "Understandable Interruptions" showed acceptance of pandemic disruptions.

Conclusion

National guidance and organizational policy impacted participants in different ways. Those who had supportive relationships and occupied time were better able to make positive use of newfound freedoms and engage with community-level support. In contrast, those who had less stability, including mental health struggles and social isolation, felt cut off and unheard, particularly from key workers. Reduced rural transport was a significant community-level issue, which impeded OST collection and social support. We suggest emergency response plans be created for individuals taking account of their pre-existing personal situations.

Trends in deaths following drug use in England before, during, and after the COVID-19 lockdowns

Aim

This research aimed to describe how the characteristics of deaths following drug use changed during the COVID-19 pandemic in England, and how this can inform future strategy to support the health and social care of people who use drugs in future emergency scenarios.

Method

All deaths reported to the National Programme on Substance Abuse Deaths which occurred between January 2018 and December 2021 inclusive were extracted for analysis. Exponential smoothing models were constructed to determine any differences between forecasted vs. actual trends.

Key results

Following the first lockdown period in England there were significant increases in the proportion of people who died at home beyond the 95% confidence bounds of the exponential smoothing model and concurrent decreases in the proportion of people who died in hospital. Whilst the overall proportion of deaths attributable to opioids did not significantly deviate from the forecasted trend, there were significant increases in methadone-related deaths and decreases in heroin/morphine-related death beyond the 95% confidence bounds. The proportion of deaths concluded as suicide increased, as did those implicating antidepressant use. There were no changes in the proportion of deaths following use of other drug classes, alcohol use in combination with psychoactive drugs, or on decedent demographics (gender, age, and drug user status). A small number of deaths due to drug use had COVID-19 infection itself listed as a cause of death (n = 23).

Conclusion

For people who use drugs, the impact of the restrictions due to the COVID-19 pandemic was greater than that of infection from the virus itself. The health and social care strategy for these people needs to be pre-emptively adapted to mitigate against the specific risk factors for fatal drug overdose associated with future emergency scenarios.

Pharmacy-based methadone treatment in the US: views of pharmacists and opioid treatment program staff

BACKGROUND

The US federal regulations allow pharmacy administration and dispensing of methadone for opioid use disorder (PADMOUD) to increase the capability of opioid treatment programs (OTPs) in providing methadone maintenance treatment (MMT) for opioid use disorder (OUD) as part of a medication unit. However, there is a lack of research data from both pharmacy and OTP staff to inform the implementation of PADMOUD.

METHODS

Staff of a pharmacy (n = 8) and an OTP (n = 9) that participated in the first completed US trial on PADMOUD through electronic prescribing for methadone (parent study) were recruited to participate in this qualitative interview study to explore implementation-related factors for PADMOUD. Each interview was recorded and transcribed verbatim. NVivo was used to help identify themes of qualitative interview data. The Promoting Action on Research Implementation in Health Services (PARIHS) framework was used to guide the coding and interpretation of data.

RESULTS

Six pharmacy staff and eight OTP staff (n = 14) completed the interview. Results based on PARIHS domains were summarized, including evidence, context, and facilitation domains. Participants perceived benefits of PADMOUD for patients, pharmacies, OTPs, and payers. PADMOUD was considered to increase access for stable patients, provide additional patient service opportunities and revenues for pharmacies/pharmacists, enhance the capability of OTPs to treat more new patients, and reduce patients' cost when receiving medication at a pharmacy relative to an OTP. Both pharmacy and OTP staff were perceived to be supportive of the implementation of PADMOUD. Pharmacy staff/pharmacists were perceived to need proper training on addiction and methadone as well as a protocol of PADMOUD to conduct PADMOUD. Facilitators include having thought leaders to guide the operation, a certification program to ensure proper training of pharmacy staff/pharmacist, having updated pharmacy service software or technology to streamline the workflow of delivering PADMOUD and inventory management, and reimbursement for pharmacists.

CONCLUSION

This study presents the first findings on perspectives of PADMOUD from both staff of a community pharmacy and an OTP in the US. Finding on barriers and facilitators are useful data to guide the development of strategies to implement PADMOUD to help address the US opioid crisis.

Patient perspectives on community pharmacy administered and dispensing of methadone treatment for opioid use disorder: a qualitative study in the U.S

BACKGROUND

Pharmacy administration and dispensing of methadone treatment for opioid use disorder (PADMOUD) may address inadequate capability of opioid treatment programs (OTPs) in the US by expanding access to methadone at community pharmacies nationally. PADMOUD is vastly underutilized in the US. There is no published US study on OUD patients' perspectives on PADMOUD. Data are timely and needed to inform the implementation of PADMOUD in the US to address its serious opioid overdose crisis.

METHODS

Patient participants of the first completed US trial on PADMOUD through electronic prescribing for methadone (parent study) were interviewed to explore implementation-related factors for PADMOUD. All 20 participants of the parent study were invited to participate in this interview study. Each interview was recorded and transcribed verbatim. Thematic analysis was conducted to identify emergent themes.

RESULTS

Seventeen participants completed the interview. Patients' perspectives on PADMOUD were grouped into five areas. Participants reported feasibility of taking the tablet formulation of methadone at the pharmacy and identified benefits from PADMOUD (e.g., better access, efficiency, convenience) compared with usual care at the OTP. Participants perceived support for PADMOUD from their family/friends, OTP staff, and pharmacy staff. PADMOUD was perceived to be a great option for stable patients with take-home doses and those with transportation barriers. The distance (convenience), office hours, and the cost were considered factors most influencing their decision to receive methadone from a pharmacy. Nonjudgmental communication, pharmacists' training on methadone treatment, selection of patients (stable status), workflow of PADMOUD, and protection of privacy were considered key factors for improving operations of PADMOUD.

CONCLUSION

This study presents the first findings on patient perspectives on PADMOUD. Participants considered pharmacies more accessible than OTPs, which could encourage more people to receive methadone treatment earlier and help transition stable patients from an OTP into a local pharmacy. The findings have timely implications for informing implementation strategies of PADMOUD that consider patients' views and needs.

Trends in Fatal Poisoning Among Drug Users in France From 2011 to 2021: An Analysis of the DRAMES Register

Importance

The DRAMES (Décès en Relation avec l'Abus de Médicaments Et de Substances) register is a database of drug-related deaths with the aim of identifying the psychoactive substances associated with and estimating the trends in these deaths. Our novel approach is based on the collection of data on all deaths for which toxicology experts have performed analyses.

Objective

To describe drug-related deaths in France and report trends over an 11-year period.

Design, Setting, and Participants

This case series used a national register to assess 4460 drug-related deaths that occurred from 2011 to 2021 in France. Data analyses were performed from January 1, 2012, to December 31, 2022.

Main Outcomes and Measures

Demographic characteristics; medical and substance abuse history; forensic autopsy findings; and toxicology reports.

Results

Among the 4460 deceased individuals (mean [SD] age, 37.8 [10.5] years), the mortality rate was highest among men (sex ratio, 4.4:1). Of the deaths involving a single or predominant drug, the legal substitution product, methadone, was the leading cause of death during the entire study period, ahead of heroin-44.7% and 35.9% for methadone vs 15.8% and 21.8% for heroin in 2011 and 2021, respectively. Between 2011 and 2021, most of the drug-related deaths shifted from licit to illicit drugs, and statistically significant variations were found for buprenorphine, cocaine, heroin, methadone, and other licit opioids. Deaths related to polydrug use increased from 23.2% in 2011 to 30.6% in 2021. In this context, opioids remained associated with most deaths, with at least 1 opioid being involved in approximately 9 of 10 cases (85.9%) in 2021. However, the main trend was the dramatic increase in drug combinations with cocaine, from less than one-third of cases in 2011 (30.8%) to more than half in 2021 (57.8%).

Conclusions and Relevance

This case series assessment of 4460 drug-related deaths found that opioids used alone or in combination were the main contributor to drug-related deaths, despite having a lower prevalence than other drugs. This finding is similar to that of other countries; however, in France licit methadone was the leading cause of opioid-related deaths (ahead of heroin) during the study period. Deaths associated with use of cannabis, new psychoactive substances, and stimulants (including amphetamine-type stimulants and cocaine, especially in combination) have increased and should be closely monitored.

Substance use disorders and COVID-19: reflections on international research and practice changes during the "poly-crisis"

Since March 2020, the COVID-19 pandemic has had a disproportionately high toll on vulnerable populations, coinciding with increased prevalence of alcohol-and drug-related deaths and pre-existing societal issues such as rising income inequality and homelessness. This poly-crisis has posed unique challenges to service delivery for people with substance use disorders, and innovative approaches have emerged. In this Perspectives paper we reflect on the poly-crisis and the changes to research and practice for those experiencing substance use disorders, following work undertaken as part of the InterGLAM project (part of the 2022. Lisbon Addictions conference). The authors, who were part of an InterGLAM working group, identified a range of creative and novel responses by gathering information from conference attendees about COVID-19-related changes to substance use disorder treatment in their countries. In this paper we describe these responses across a range of countries, focusing on changes to telehealth, provision of medications for opioid use disorder and alcohol harm reduction, as well as changes to how research was conducted. Implications include better equity in access to technology and secure data systems; increased prescribed safer supply in countries where this currently does not exist; flexible provision of medication for opioid use disorder; scale up of alcohol harm reduction for people with alcohol use disorders; greater involvement of people with lived/living experience in research; and additional support for research in low- and middle-income countries. The COVID-19 pandemic has changed the addictions field and there are lessons for ongoing and emerging crises.

Examination of methadone involved overdoses during the COVID-19 pandemic

BACKGROUND

The US opioid overdose epidemic continues to escalate. The restrictions on methadone availability including take-home dosing were loosened during the COVID-19 pandemic although there have been concerns about the high street value of diverted methadone. This report examined how fatal overdoses involving methadone have changed over the past two-decades including during the pandemic.

METHODS

The CDC's Wide-ranging Online Data for Epidemiologic Research (WONDER) was used to find the unintentional methadone related overdose death rate from 1999 to 2020. Unintentional methadone deaths were defined using the ICD X40-44 codes with only data for methadone (T40.3). Data from the DEA's Automation of Reports and Consolidated Orders System (ARCOS) on methadone overall use, opioid treatment programs use, and pain management use was gathered for all states for 2020 and corrected for population.

RESULTS

There have been dynamic changes over the past two-decades in methadone overdoses. Overdoses increased from 1999 (0.9/million) to 2007 (15.9) and declined until 2019 (6.5). Overdoses in 2020 (9.6) were 48.1% higher than in 2019 (t(50) = 3.05, p < .005). The state level correlations between overall methadone use (r(49) = +0.75, p < .001), and opioid treatment program use (r(49) = +0.77, p < .001) with overdoses were positive, strong, and statistically significant. However, methadone use for pain treatment was not associated with methadone overdoses (r(49) = -0.08).

CONCLUSIONS

Overdoses involving methadone significantly increased by 48.1% in 2020 relative to 2019. Policy changes that were implemented following the COVID-19 pandemic involving methadone take-homes may warrant further study before they are made permanent.

Methadone-involved overdose deaths in the United States before and during the COVID-19 pandemic

BACKGROUND

Few studies have characterized methadone-involved overdose deaths in the US since 2014 despite changing patterns of opioid use, the onset of the COVID-19 pandemic, and changes to take-home dose guidance in opioid treatment programs (OTPs) in March 2020.

METHODS

Data on monthly overdose deaths in the US from January 1, 2007 to March 31, 2021 were obtained through CDC WONDER. Interrupted time series models were used to assess for changes in series levels starting in April 2020. Analyses were stratified by involvement of synthetic opioids in overdose deaths.

RESULTS

An increase in methadone-involved overdoses of 105.4 deaths per month (95 % CI: 73.8-137.0) occurred starting in April 2020 compared with prior trends (p < 0.001). Trends in methadone-involved overdose deaths showed a step increase starting in April 2020 both with (54.2 deaths per month; 95 % CI: 39.4-68.9) and without (51.7 deaths per month; 95 % CI: 23.4-78.0) synthetic opioid involvement (p < 0.001 for both). Among overdose deaths without synthetic opioids, the increase in methadone-involved overdose deaths accounted for 26.5 % of the increase between the 12-month periods before and after March 2020. The relative percentage increase in methadone-involved overdose deaths, both with and without synthetic opioid co-involvement, was highest among Hispanic and non-Hispanic Black individuals.

CONCLUSIONS

Methadone-involved overdose deaths, both with and without other synthetic opioid co-involvement, increased during the 12-month period after March 2020, compared with prior trends. These results provide a cautionary addition to previous findings of no or limited methadone-related harms after the US regulatory changes during the COVID-19 pandemic.

Exploring the Role of DARPP-32 in Addiction: A Review of the Current Limitations of Addiction Treatment Pathways and the Role of DARPP-32 to Improve Them

We are amidst a global addiction crisis, yet stigmas surrounding addiction counterintuitively prevail. Understanding and appreciating the neurobiology of addiction is essential to dissolve this stigma and for the development of new pharmacological agents to improve upon currently narrow therapeutic options. This review highlights this and evaluates dopamine-and-cAMP-regulated phosphoprotein, Mr 32 kDa (DARPP-32) as a potential target to treat various forms of substance abuse. Despite the proven involvement of DARPP-32 in addiction pathophysiology, no robust investigations into compounds that could pharmacologically modulate it have been carried out. Agents capable of altering DARPP-32 signalling in this way could prevent or reverse drug abuse and improve upon currently substandard treatment options.

The effect of a methadone reformulation on opioid agonist treatment outcomes: A population-based study in British Columbia, Canada, 2013-14

INTRODUCTION

The province of British Columbia, Canada, changed the existing oral anhydrous methadone solution to a 10-times more concentrated pre-mixed solution, Methadose®, on February 1, 2014. We aimed to assess the immediate effects of the methadone reformulation on missed doses, days off methadone, changes in medication dosing and dispensations of opioids for pain, and hospitalizations and mortality among all people receiving treatment at or near the time of the change.

METHODS

We conducted a population-based retrospective cohort study including all individuals receiving at least one methadone dispensation in the 12 months prior to the study period. We executed a difference-in-differences analysis by estimating a multivariate regression model to compare outcomes in the three months before and after the reformulation (November 1, 2013 to April 30, 2014) versus a time-lagged control cohort with similar characteristics observed during an equivalent nonoverlapping interval. We used daily individual-level linked health administrative data capturing missed doses, days off methadone, changes in methadone dosing, concurrent dispensations of opioids for pain, hospitalizations, and mortality. We stratified the cohorts into three subgroups: (i) those receiving OAT for ≥12 months; (ii) those receiving OAT for <12 months; and (iii) those not receiving OAT at the start of the study period. We conducted sensitivity analyses and placebo tests to assess the robustness of our results.

RESULTS

Among the 16,339 individuals receiving methadone during the study period, the reformulation was associated with more instances of methadone dose increases (34.5% [95% Confidence Interval (CI): 27.4%, 41.5%]). For those retained in treatment ≥12 months prior to the study period (n = 7449), the reformulation was associated with more instances of methadone dose increases (50.2% [39.5%, 60.8%]) and dispensations of opioids for pain (62.2% [40.8%, 83.5%]), as well as an increase in missed doses (41.9% [29.1%, 54.7%]) and days off methadone (62.6% [39.7%, 85.4%]). We found no statistically significant change in risk of hospitalization or mortality. Sensitivity analyses supported our results.

CONCLUSION

Our results reinforce the need expressed by people receiving methadone for greater client involvement in the planning and implementation of regulatory changes that may impact client care, especially those patients with a relatively long treatment history.

Fatalities associated with gabapentinoids in England (2004-2020)

The gabapentinoids were reclassified as Schedule II medications and Class C drugs in the UK in 2019 due to their potential misuse. In this study we examined deaths following gabapentinoid use in England reported to the National Programme on Substance Abuse Deaths.

A total of 3051 deaths were reported (gabapentin: 913 cases; pregabalin: 2322 cases [both detected in 184 cases]). Prescribed and illicitly obtained gabapentinoids accounted for similar proportions of deaths (gabapentin illicit 38.0%, prescribed 37.1%; pregabalin illicit 41.0%, prescribed 34.6%). Opioids were co‐detected in most cases (92.0%), and co‐prescribed in a quarter (25.3%). Postmortem blood gabapentinoid concentrations were commonly (sub)therapeutic (65.0% of gabapentin cases; 50.8% of pregabalin cases). In only two cases was gabapentinoid toxicity alone attributed in causing death.

Gabapentinoids alone rarely cause death. Clinically relevant doses can, however, prove fatal, possibly by reducing tolerance to opioids. Doctors and patients should be aware of this interaction.

Gabapentinoid–opioid co‐prescribing needs urgent revision.

Opioid treatment program and community pharmacy collaboration for methadone maintenance treatment: results from a feasibility clinical trial

BACKGROUND AND AIMS

Pharmacy administration and dispensing of methadone for methadone maintenance treatment (MMT) can expand treatment access for opioid use disorder (OUD). This study investigated the feasibility and acceptability of a novel model permitting an opioid treatment program (OTP) physician to prescribe methadone for OUD treatment through collaboration with a partnered pharmacy.

DESIGN

Non-randomized, single-arm, open-label feasibility trial.

SETTING

One OTP and one community pharmacy in the United States.

PARTICIPANTS

One OTP physician, two pharmacists and 20 MMT patients receiving between six and 13 take-home methadone doses at 5-160 mg/day.

INTERVENTION

Patients' methadone administration and dispensing of take-home doses was transferred from the OTP to the pharmacy for 3 months.

MEASUREMENTS

Primary outcome was medication adherence. Secondary outcomes were recruitment, treatment retention, substance use, counseling attendance at the OTP, pharmacist prescription drug monitoring program (PDMP) use, safety and satisfaction.

FINDINGS

Of 29 patients eligible at pre-screen, 20 patients (69%) enrolled into the study. Recruitment occurred from 6 August 2020 to 10 October 2020. Treatment retention rate at month 3 was 80% (16 of 20). Two participants returned early to the OTP because of a work/schedule change, one due to pregnancy and one following a non-study-related hospitalization. Medication adherence among 16 patients who were retained was 100%. Intervention fidelity was 100%. All participants attended random call-back visits. None showed evidence of tampering/diversion of methadone. Pharmacists checked the PDMP at all visits. All participants attended psychosocial counseling as planned. There were no positive urine screens for illicit opioid use and no study-related adverse events. All participants endorsed 'pharmacy is the right location for receiving methadone for MMT', 88% endorsed 'convenient or very convenient to receive methadone at the pharmacy' and 88% were satisfied or very satisfied with the quality of treatment offered.

CONCLUSIONS

This feasibility trial has found pharmacy administration and dispensing of physician-prescribed methadone for methadone maintenance treatment to be feasible and acceptable.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Analisi di Budget Impact della formulazione depot di buprenorfina a rilascio prolungato per la gestione di pazienti affetti da disturbo da uso di oppiacei

Background:

Opioid use disorder (OUD) is a disorder associated with significant rate of morbidity and mortality. Frequent clinic attendance for supervised consumption of sublingual buprenorphine is common. Prolonged-release buprenorphine (PRB) allows a management based on weekly or monthly subcutaneous injections, thus limiting the burdens of clinic attendance and the risks associated with sublingual formulations.

Objective:

To determine the price level of PRB that allows to obtain a neutral impact from the point of view of the economic resources absorbed, in comparison with the alternatives currently available in the Italian context for the management of patients suffering from OUD.

Methods:

The analysis assumes a daily PRB cost of € 8.526 (neutral cost). The analysis aims to determine the economic impact associated with the introduction of PRB in the Italian context for the management of OUD patients. Results are expressed in terms of differential resources absorbed in the alternative scenarios. A one-way sensitivity analysis was also carried out to test the robustness of the results.

Results:

The introduction of PRB implies an increase in the drug acquisition costs over the 5-year time horizon of € 23,016,194.61: such costs are fully compensated by the other cost driver considered in the analysis (drug tests provided, health professionals’ time destined to the provision of the treatment, indirect costs, for savings equal to € 7,255,602.59, € 10,714,320.08 and € 5,046,271.94 respectively) demonstrating its effectiveness in particular by an organizational point of view. Lower price levels for PRB would imply significant savings for the SSN.

Conclusions:

PRB resulted to be associated to a lower level of resources’ absorption in the Italian sector as compared with the available alternatives thus allowing to re-allocate health founds to other fields of the care sector ensuring greater safety for patients and a decreased misuse and diversion rate.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Scotland's 2009-2015 methadone-prescription cohort: Quintiles for daily dose of prescribed methadone and risk of methadone-specific death

AIMS

As methadone clients age, their drug-related death (DRD) risks increase, more than doubling at 45+ years for methadone-specific DRDs.

METHODS

Using Community Health Index (CHI) numbers, mortality to 31 December 2015 was ascertained for 36 347 methadone-prescription clients in Scotland during 2009-2015. Cohort entry, quantity of prescribed methadone and daily dose (actual or recovered by effective, simple rules) were defined by clients' first CHI-identified methadone prescription after 30 June 2009 and used in proportional hazards analysis. As custodian of death records, National Records of Scotland identified non-DRDs from DRDs. Methadone-specific DRD means methadone was implicated but neither heroin nor buprenorphine.

RESULTS

The cohort's 192 928 person-years included 1857 non-DRDs and 1323 DRDs (42%), 546 of which were methadone specific. Actual/recovered daily dose was available for 26 533 (73%) clients who experienced 420 methadone-specific DRDs. Top quintile for daily dose at first CHI-identified methadone prescription was >90 mg. Age 45+ years at cohort-entry (hazard ratio vs 25-34 years: 3.1, 95% confidence interval: 2.4-4.2), top quintile for baseline daily dose of prescribed methadone (vs 50-70 mg: 1.9, 1.1-3.1) and being female (1.3, 1.0-1.6) significantly increased clients' risk of methadone-specific DRD.

CONCLUSION

Extra care is needed when methadone daily dose exceeds 90 mg. Females' higher risk for methadone-specific DRD is new and needs validation. Further analyses of prescribed daily dose linked to mortality for large cohorts of methadone clients are needed internationally, together with greater pharmacodynamic and pharmacokinetic understanding of methadone by age and sex. Balancing age-related risks is challenging for prescribers who manage chronic opiate dependency against additional uncertainty about the nature, strength and pharmacological characteristics of drugs from illegal markets.

Methadone-related deaths among youth and young adults in Sweden 2006-15

AIMS

To identify methadone-related deaths and determine the prevalence among youth and young adults in Sweden 2006-15.

DESIGN, SETTING AND PARTICIPANTS

National retrospective registry study comparing data from all forensic autopsy examinations and toxicology cases involving methadone during 2006-15 in individuals aged 15-29 years with police records, previous pharmaceutical prescriptions and health-care episodes.

MEASUREMENTS

Multinomial logistic regression. To assess the factors contributing to the deaths, we compared individuals with and without previous substance use treatment and opioid use-related diagnoses with regard to previous opioid agonist treatment (OAT), psychiatric care and previous pain medication. To assess the circumstances of deaths, we analyzed the presence of other drugs and other factors at time of death.

FINDINGS

We identified 269 methadone-related deaths, and the rate increased during the study period. Seventy-two (27%) cases had not previously received substance use treatment, 112 (42%) had received treatment but had no opioid use-related diagnosis and 85 (32%) had received treatment and had an opioid use-related diagnosis. In total, only 10 individuals had been prescribed methadone during the year before death. Prescriptions of benzodiazepines (60%), antidepressants (62%) and opioids for pain (22%) the year before death were common. Most deaths occurred during sleep with a time lag from ingestion of methadone.

CONCLUSION

Prescription opioid- and methadone-related deaths increased in the group aged 15-29 years in Sweden between 2006 and 2015. Exposure to non-prescribed methadone and prescribed benzodiazepines, antidepressants and opioids for pain appears to be common in drug-related deaths in youth and young adults in Sweden.

Global opioid agonist treatment: a review of clinical practices by country

AIMS

We assessed how opioid agonist treatment (OAT) for opioid use disorder (OUD), specifically methadone and buprenorphine, including buprenorphine-naloxone, is delivered in routine clinical practice, with a focus on factors that affect access to and delivery of these services. The aims of this review were to summarize eligibility criteria for entry to OAT, doses in routine clinical practice, access to and eligibility for unsupervised dosing and urine drug screening practices in OAT programs globally.

METHODS

We completed searches of PubMed, Embase, and grey literature databases for cross-sectional or observational cohort studies of OAT using either methadone or buprenorphine. Dose data extracted from eligible studies were compared with guidelines provided by WHO.

RESULTS

We found 140 reports from 41 countries that contained data for at least one of the relevant indicators. A diagnosis of opioid dependence or opioid use disorder was the most common eligibility requirement for OAT (13 or 17 countries). Reported mean or median doses for methadone ranged from 16-131 mg whereas range for buprenorphine was 2.5-19 mg. Access to unsupervised dosing under some conditions was reported in 18 of 27 countries. Frequency of regular urine drug screenings (UDS) ranged from several times a week to eight times per year (methadone) or as clinically indicated.

CONCLUSIONS

Opioid agonist treatment practices, including doses prescribed, vary greatly both within and across countries. Of particular concern is the persistence of lower dose prescribing practices, in which patients may be prescribed doses below those proven to yield significant clinical benefits.

Rapid transitional response to the COVID-19 pandemic by opioid agonist treatment programs in Ukraine

On March 16, 2020, Ukraine's Ministry of Health issued nonspecific interim guidance to continue enrolling patients in opioid agonist therapies (OAT) and transition existing patients to take-home dosing to reduce community COVID-19 transmission. Though the number of OAT patients increased modestly, the proportion receiving take-home dosing increased from 57.5% to 82.2%, which translates on average to 963,952 fewer clinic interactions annually (range: 728,652-1,016,895) and potentially 80,329 (range: 60,721-84,741) fewer hours of in-person clinical encounters. During the transition, narcologists (addiction specialists) expressed concerns about overdoses, the guidance contradicting existing legislation, and patient dropout, either from incarceration or inadequate public transportation. Though clinicians did observe some overdoses, short-term overall mortality remained similar to the previous year. As the country relaxes the interim guidance, we do not know to what extent governmental guidance or clinical practice will change to adopt the new guidance permanently or revert to pre-guidance regulations. Some future considerations that have come from COVID-19 are should dosing schedules continue to be flexible, should clinicians adopt telehealth, and should there be more overdose education and naloxone distribution? OAT delivery has improved and become more efficient, but clinicians should plan long-term should COVID-19 return in the near future. If the new efficiencies are maintained, it will free the workforce to further scale up OAT.

Opioid use disorder and the COVID 19 pandemic: A call to sustain regulatory easements and further expand access to treatment

We highlight the critical roles that pharmacists have related to sustaining and advancing the changes being made in the face of the current COVID-19 pandemic to ensure that patients have more seamless and less complex access to treatment. Discussed herein is how the current COVID-19 pandemic is impacting persons with substance use disorders, barriers that persist, and the opportunities that arise as regulations around treatments for this population are eased.

Unintentional Drug-related Deaths in Cambridgeshire: A Retrospective Observational Study

BACKGROUND

 Drug-related deaths are a growing public health problem in the United Kingdom, overtaking road fatalities and homicides in terms of annual deaths. In this study, we investigated the causes and circumstances of unintentional drug-related deaths occurring in the county of Cambridgeshire, with the objective of identifying the prevalence of physical, mental, and social health problems within this cohort.

METHODS

 We collected data on the demographics and mental and physical health of, and drugs contributing to, 30 consecutive unintentional drug-related deaths recorded by the Cambridgeshire and Peterborough County Council Coroners in 2017. A retrospective observational study was used, and data were collected by manual extraction from coroners' files.

RESULTS

 Social isolation was identified as a recurring theme amongst the decedents, although homelessness was found in very few cases. Pharmacologically, multiple drug toxicity and opioid toxicity were highly prevalent, whilst prescription opioids were implicated in more cases than heroin. Chronic pain was also highly prevalent amongst the decedents, and a history of mental illness was found to occur in the majority of cases.

DISCUSSION

 Our findings show that reports from the coronial system provide a rich narrative to understand the causes of drug-related deaths. We have identified that individuals who die from drug-related deaths frequently have multiple adverse physical, mental, and social problems. This implies that any attempt to reduce drug-related deaths requires a multi-faceted and multi-disciplinary approach.

Medication Treatment of Opioid Use Disorder

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.

Characteristics Associated with Nonmedical Methadone Use among People Who Inject Drugs in California

Background: Illicit, nonmedical use of opioid agonist medications such as methadone is an ongoing concern. Yet, few studies have examined nonmedical use of methadone by people who inject drugs (PWID). Objectives: This study describes the prevalence of nonmedical methadone use in a community sample of PWID and examines factors associated with recent use of nonmedical methadone. Methods: A cross-sectional sample of PWID (N = 777) was recruited using targeted sampling and interviewed in California (2011-2013). Descriptive, bivariate, and multivariate logistic regression analyses were used to determine characteristics associated with nonmedical methadone use in the last 30 days. To determine if nonmedical methadone use was associated with overdose in the last 6 months, a separate multivariate analysis was conducted. Results: Among PWID sampled, 21% reported nonmedical methadone use in the last 30 days. In multivariate logistic regression analysis, nonmedical methadone use was associated with recent methadone maintenance treatment (adjusted odds ratio [AOR] = 2.86; 95% confidence interval [CI] = 1.90, 4.30), recent nonmedical buprenorphine use (AOR = 3.12; 95% CI = 1.31, 7.47), higher injection frequency (referent <30 injections; 30-89 injections AOR = 1.89; 95% CI = 1.19, 3.02; 90-plus injections AOR = 2.43; 95% CI = 1.53, 3.87), schizophrenia diagnosis (AOR = 2.36; 95% CI = 1.36, 4.10), recent non-injection opioid prescription use (AOR = 2.97; 95% CI = 1.99, 4.43), and recent injection opioid prescription misuse (AOR = 2.13; 95% CI = 1.27, 3.59). Nonmedical methadone use was found not to be associated with nonfatal overdose (AOR = 0.77; 95% CI = 0.38, 1.56). Conclusion: Nonmedical methadone use identifies a vulnerable subpopulation among PWID, is not associated with elevated nonfatal overdose risk, and evidences a need to expand methadone treatment availability.

Global patterns of opioid use and dependence: harms to populations, interventions, and future action

We summarise the evidence for medicinal uses of opioids, harms related to the extramedical use of, and dependence on, these drugs, and a wide range of interventions used to address these harms. The Global Burden of Diseases, Injuries, and Risk Factors Study estimated that in 2017, 40·5 million people were dependent on opioids (95% uncertainty interval 34·3-47·9 million) and 109 500 people (105 800-113 600) died from opioid overdose. Opioid agonist treatment (OAT) can be highly effective in reducing illicit opioid use and improving multiple health and social outcomes-eg, by reducing overall mortality and key causes of death, including overdose, suicide, HIV, hepatitis C virus, and other injuries. Mathematical modelling suggests that scaling up the use of OAT and retaining people in treatment, including in prison, could avert a median of 7·7% of deaths in Kentucky, 10·7% in Kiev, and 25·9% in Tehran over 20 years (compared with no OAT), with the greater effects in Tehran and Kiev being due to reductions in HIV mortality, given the higher prevalence of HIV among people who inject drugs in those settings. Other interventions have varied evidence for effectiveness and patient acceptability, and typically affect a narrower set of outcomes than OAT does. Other effective interventions focus on preventing harm related to opioids. Despite strong evidence for the effectiveness of a range of interventions to improve the health and wellbeing of people who are dependent on opioids, coverage is low, even in high-income countries. Treatment quality might be less than desirable, and considerable harm might be caused to individuals, society, and the economy by the criminalisation of extramedical opioid use and dependence. Alternative policy frameworks are recommended that adopt an approach based on human rights and public health, do not make drug use a criminal behaviour, and seek to reduce drug-related harm at the population level.

Age differences in emergency department utilization and repeat visits among patients with opioid use disorder at an urban safety-net hospital: A focus on young adults

BACKGROUND

Opioid use disorder (OUD) among young adults from ages 18 to 25 years is increasing in the United States. Emergency departments (EDs) are recognized as major sources of care for patients with OUD, but questions remain about ED utilization among this population. We examined the demographics and ED utilization patterns at an urban safety-net hospital with a focus on young adults to inform intervention development.

METHODS

We extracted demographic and clinical data from electronic medical records of patients ages 18 to 64 years diagnosed with OUD between 2013 and 2017. Descriptive statistics were assessed, including race/ethnicity, sex, insurance, other substance use disorder and mental health diagnoses, and ED utilization patterns by age group. Univariable and multivariable logistic regressions were performed to analyze the associations between age and ED utilization patterns.

RESULTS

Among 12,025 OUD patients in the sample, 30% had an ED visit with a primary diagnosis of OUD. Among those who had an ED visit, 48% had at least one additional ED visit within a year. The probability of ED visits (adjusted odds ratio [AOR]:5.04; 95% confidence interval [CI]:4.14-6.13) and repeat ED visits (AOR:3.28; CI:2.53-4.26) were significantly higher among young adults (18-25 years) compared to the oldest age group (56-64 years).

CONCLUSIONS

Compared to older adults, young adults with OUD are more likely to use the ED and to have repeat ED visits. The identification of youth-tailored interventions in the ED within broader efforts to address the opioid epidemic should be an urgent priority.

Non-prescribed use of methadone and buprenorphine prior to opioid substitution treatment: lifetime prevalence, motives, and drug sources among people with opioid dependence in five Swedish cities

BACKGROUND

Opioid substitution treatment (OST) with methadone or buprenorphine is the most effective means of treating opioid dependence. If these substances are used by people who are not undergoing OST, they can however carry serious risks. This article examines the lifetime prevalence, motives, and drug sources for such use, as well as geographical differences in these variables.

METHODS

Structured interviews were conducted with 411 patients from 11 OST clinics in five Swedish cities. The researchers carried out 280 interviews on-site, while 131 interviews were conducted by specially trained patients through privileged access interviewing. Data were analyzed by frequency and average calculations, cross-tabulations, and χ2 tests.

RESULTS

The lifetime prevalence of non-prescribed use was 87.8% for methadone, 80.5% for buprenorphine, and 50.6% for buprenorphine/naloxone. Pseudo-therapeutic motives-avoiding withdrawal symptoms, staying clean from heroin, detoxification, or taking care of one's own OST-were commonly cited as driving the use, while using the drugs for euphoric purposes was a less common motive. Most respondents had bought or received the substances from patients in OST, but dealers were also a significant source of non-prescribed methadone and buprenorphine. Geographical differences of use, motives, and sources suggest that prescription practices in OST have a great impact on which substances are used outside of the treatment.

CONCLUSIONS

Experiences of non-prescribed use of methadone and buprenorphine are extremely common among those in OST in southern Sweden. As the use is typically driven by pseudo-therapeutic motives, increased access to OST might decrease the illicit demand for these substances. Buprenorphine/naloxone has a lower abuse potential than buprenorphine and should therefore be prioritized as the prescribed drug. Supervised dosage and other control measures are important provisions in the prevention of drug diversion and non-prescribed use among people not undergoing OST.

Non drug-related and opioid-specific causes of 3262 deaths in Scotland's methadone-prescription clients, 2009-2015

BACKGROUND

Opioid drug use is a major cause of premature mortality, with opioid substitution therapy the leading intervention. As methadone-clients age, non-drug-related deaths (non-DRDs) predominate and DRD-risks increase differentially, quadrupling at 45+ years for methadone-specific DRDs.

METHODS

36,606 methadone-prescription-clients in Scotland during 2009-2015 were linked to mortality records to end-2015 by their Community Health Index (CHI). Cohort-entry, also baseline quantity of prescribed methadone, were defined by clients' first CHI-identified methadone-prescription during 2009-2015. National Records of Scotland identified non-DRDs from DRDs; and provided ICD10 codes for underlying and co-present causes of death. Methadone-specific DRD means methadone was implicated in DRD but neither heroin nor buprenorphine.

RESULTS

During 193,800 person-years of follow-up, 1939 non-DRDs (59%) and 1323 DRDs occurred, of which 546 were methadone-specific. Predominant underlying ICD10 chapters for non-DRDs were: neoplasm (377); external causes (341); diseases of digestive (303), circulatory (286) or respiratory (212) system. As methadone-clients aged, the non-DRD proportion of their deaths increased from 54% (717/1318) at 35-44 years to 89% (372/417) at 55+ years. After allowing for DRDs' opioid-specificity, age-group and quintile for last-prescribed methadone, there was a significant, positive interaction for co-present circulatory disease between top-quintile for prescribed methadone and 45+ years at death (p = 0.033 after Bonferroni); not for digestive or respiratory co-presence.

CONCLUSIONS

Circulatory disease is the co-morbidity most likely implicated in the quadrupling of methadone-specific DRD-risk at 45+ years; followed by digestive disease. Cultural shift is needed in treatment-services because degenerative non-DRDs predominate as methadone-clients age. Future linkage-studies should access hospitalizations and methadone-daily-dose.

Community pharmacists' role in preventing opioid substitution therapy-related deaths: a qualitative investigation into current UK practice

Background Opioid substitution therapy involves prescribing of medical substitutes like methadone and buprenorphine to patients who are addicted to opioids. The majority of opioid substitution therapy dispensing in the UK is done by community pharmacists and they often see the patients on daily basis. It is unknown to what extent community pharmacists implement the policy to prevent overdose in patients receiving such treatment. Objective To explore what UK community pharmacists think about their role in preventing opium substitution-related deaths, their understanding of the risks associated with this substitution therapy and their views on what else community pharmacists could do to reduce such deaths. Setting Twenty four community pharmacists from two areas in UK (Worcestershire and Bath and North East Somerset). Method  Between January and March 2013, community pharmacists providing opoin substitution therapy were interviewed in their pharmacy, using semi-structured interviews. Interpretative Phenomenology Analysis was used to analyse the data. Main outcome measure Thematically organised description of professional practice as reported by the participants against the clinical/practice guidance for opioid substitution therapy in UK. Results While participants felt their role to be essential in providing the service, they did not feel part of an integrated system. Participants’ ability to act in risk situations was affected by their knowledge, confidence in intervening in such situation, as well as the support they receive in providing the service. Conclusion Participants reported large differences in how ‘opioid substitution therapy’ services are provided in community pharmacy. Lack of knowledge among some pharmacists and lack of support in providing the service resulted in some patients at high risk not having their risks acted upon.

The impact of opiate substitution treatment on mortality risk in drug addicts: a natural experiment study

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.

Methadone Maintenance Treatment: A 15-year Retrospective Study in Split-Dalmatia County, Croatia

BACKGROUND

The aim of this retrospective study is to use existing epidemiological data on patients in methadone maintenance treatment in Split-Dalmatia County from 2001 to 2015 to evaluate the substitution treatment system and policy of opiate addicts treatment, the epidemiological trend, and risk of overdose mortality. In addition, we would like to highlight the problem of poor control of methadone therapy and thus the possibility of selling methadone. The result is a greater number of deaths caused by methadone in people who were not in methadone therapy.

METHODS

The research included data collected from 3189 patients who had been in the drug abuse treatment program in Split-Dalmatia County during 2001-2015 and data gathered from autopsy examinations of patients in Split-Dalmatia County with emphasis on data for 186 overdosed patients during research period.

RESULTS

The total number of patients in the methadone treatment program in Split-Dalmatia County during the research period, except in 2005 and 2006, has been stable, while the number of new opiate patients, being in first-time treatment, decreased by 62.5%. The number of addicts who were in a long-term maintenance program has increased by 198%, whereas the number of addicts who were in a short-term detoxification treatment has decreased by 96.4%. According to results obtained from performed autopsies, 186 death cases were determined as overdoses. Methadone was found in 56 of those cases and was declared as the cause of death in 39 cases (70%). Of the total number of autopsied patients with diagnosed methadone overdose, only 23 (59%) had been recorded to receive methadone therapy in Public Health Institute of Split-Dalmatia County database.

CONCLUSIONS

The results of this study show the favorable epidemiological trend because of the decreasing number of new opiate patients in treatment. The retention of opiate patients in substitution therapy indicates the effectiveness of methadone maintenance programs. Our research did not determine any influence of methadone substitution therapy on an increasing risk of specific (overdose) mortality.

Correlations between population-levels of prescription opioid dispensing and related deaths in Ontario (Canada), 2005-2016

Canada is experiencing an ongoing opioid-related public health crisis, including persistently rising opioid (e.g., poisoning) mortality. Previous research has documented marked correlations between population-levels of opioid dispensing and deaths. We examined possible correlations between annual population-level dispensing of specific opioid formulations and related poisoning deaths in Ontario (Canada), for the period 2005-2016. Annual coroner statistics-based numbers of poisoning deaths associated with six main opioid formulations (codeine, fentanyl, hydromorphone, methadone, morphine, and oxycodone) for Ontario were converted into annual death rates (per 100,000 population). Annual dispensing data for the opioid formulations under study were based on commercial retail-sales data from a representative, stratified sample of community pharmacies (IMSQuintiles/IQVIA CompuScript), converted into Defined Daily Doses (DDD/1,000 population/day). Possible relationships between the annual death and dispensing rates were assessed by Pearson's correlation coefficient analyses. Death rates increased for almost all, while dispensing rates increased for half of the opioid categories. A significant positive correlation between death and dispensing rates was found for hydromorphone (r = 0.97, 95% CI: 0.88-0.99) and oxycodone (r = 0.90, 95% CI: 0.68-0.97) formulations; a significant negative correlation was found for codeine (r = -0.78, 95% CI: -0.93 to -0.37). No significant correlations were detected for fentanyl, methadone, and morphine related deaths. Strong correlations between levels of dispensing and deaths for select opioid formulations were found. For select others, extrinsic factors - e.g., increasing involvement of non-medical opioid products (e.g., fentanyl) in overdose deaths - likely confounded underlying correlation effects. Opioid dispensing levels continue to influence population-level mortality levels, and need to be addressed by prevention strategies.

[Improve the benefit/risk balance of methadone by respecting its pharmacological specificities]

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.

The impact of buprenorphine and methadone on mortality: a primary care cohort study in the United Kingdom

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.

Ageing opioid users' increased risk of methadone-specific death in the UK

BACKGROUND

The first evidence that the hazard ratio (HR) for methadone-specific death rises more steeply with age-group than for all drug-related deaths (DRDs) came from Scotland's cohort of 33,000 methadone-prescription clients. We aim to examine, for England, whether illicit opioid users' risk of methadone-specific death increases with age; and to pool age-related HRs for methadone-specific deaths with those for Scotland's methadone-prescription clients.

METHODS

The setting is all services in England that provide publicly-funded, structured treatment for illicit opioid users, the methodology linkage of the English National Drug Treatment Monitoring System and mortality database, and key measurements are DRDs, methadone-specific DRDs, or heroin-specific DRDs, by age-group and gender, with proportional hazards adjustment for substances used, injecting status and periods in/out of treatment.

RESULTS

Linkage was achieved for 129,979 adults receiving prescribing treatment modalities for opioid dependence during April 2005 to March 2009 and followed-up for 378,009 person-years (pys). There were 1,266 DRDs: 271 methadone-specific (7 per 10,000 pys: irrespective of gender) and 473 heroin-specific (15 per 10,000 pys for males, 7 for females). Methadone-specific DRD-rate per 10,000 person-years was 3.5 (95% CI: 2.7-4.4) at 18-34 years, 8.9 (CI: 7.3-10.5) at 35-44 years and 18 (CI: 13.8-21.2) at 45+ years; heroin-specific DRD-rate was unchanged with age. Relative to 25-34 years, pooled HRs for UK clients' methadone-specific deaths were: 0.87 at <25 years (95% CI: 0.56-1.35); 2.14 at 35-44 years (95% CI: 1.76-2.60); 3.75 at 45+ years (95% CI: 2.99-4.70).

CONCLUSION

International testing and explanation are needed of UK's sharp age-related increase in the risk of methadone-specific death. Clients should be alerted that their risk of methadone-specific death increases as they age.

Multiple Systems Estimation (or Capture-Recapture Estimation) to Inform Public Policy

Estimating population sizes has long been of interest, from the estimation of the human or ecological population size within regions or countries to the hidden number of civilian casualties in a war. Total enumeration of the population, for example, via a census, is often infeasible or simply impractical. However, a series of partial enumerations or observations of the population is often possible. This has led to the ideas of capture-recapture methods, which have been extensively used within ecology to estimate the size of wildlife populations, with an associated measure of uncertainty, and are most effectively applied when there are multiple capture occasions. Capture-recapture ideology can be more widely applied to multiple data-sources, by the linkage of individuals across the multiple lists. This is often referred to as Multiple Systems Estimation (MSE). The MSE approach has been preferred when estimating "capture-shy" or hard-to-reach populations, including those caught up in the criminal justice system; or homeless; or trafficked; or civilian casualties of war. Motivated by a range of public policy applications of MSE, each briefly introduced, we discuss practical problems with potentially substantial methodological implications. They include: "period" definition; "case" definition; when an observed count is not a true count of the population of interest but an upper bound due to mismatched definitions; exact or probabilistic matching of "cases" across different lists; demographic or other information about the "case" which may influence capture-propensities; required permissions to access extant-lists; list-creation by research-teams or interested parties; referrals (if presence on list A results - almost surely - in presence on list B); different mathematical models leading to widely different estimated population sizes; uncertainty in estimation; computational efficiency; external validation; hypothesis-generation; and additional independent external information. Returning to our motivational applications, we focus on whether the uncertainty which qualified their estimates was sufficiently narrow to orient public policy; and, if not, what options were available and/or taken to reduce the uncertainty or to seek external validation. We also consider whether MSE was hypothesis-generating: in the sense of having spawned new lines of inquiry.

Increasing diversion of methadone in Vancouver, Canada, 2005-2015

BACKGROUND AND AIM

Although methadone, an opioid agonist, has been an effective medication used to treat opioid use disorder for over 40years, recent studies have found that methadone was identified in more than a quarter of prescription opioid-related deaths among people who use illicit drugs in Vancouver, Canada. Thus, we sought to longitudinally examine the availability of diverted methadone among people who inject drugs (PWID).

DESIGN AND METHODS

Data were collected from three prospective cohorts of PWID in Vancouver, Canada between December 2005 and May 2015. Multivariable generalized estimating equation logistic regression was used to identify temporal trends in the immediate availability of diverted methadone (defined as the ability to acquire illicit methadone in <10min).

RESULTS

A total of 2092 participants, including 727 (34.8%) women, were included in the present study. In the multivariable analyses after adjusting for a range of potential confounders, later calendar year (adjusted odds ratio [AOR]=1.21 per year; 95% confidence interval [CI]: 1.19-1.23) was independently and positively associated with reporting immediate availability of diverted methadone.

CONCLUSIONS

We observed a significant increase in the reported availability of diverted methadone among PWID over a ten-year follow-up period. Further research is needed to identify strategies to limit methadone diversion and assess the impact of alternative medications that are equally effective but safer, such as buprenorphine/naloxone.

Trends in heroin and pharmaceutical opioid overdose deaths in Australia

BACKGROUND

There has been international concern over the rise in fatal pharmaceutical opioid overdose rates, driven by increased opioid analgesic prescribing. The current study aimed to examine trends in opioid overdose deaths by: 1) opioid type (heroin and pharmaceutical opioids); and 2) age, gender, and intent of the death assigned by the coroner.

METHODS

Analysis of data from the National Coronial Information System (NCIS) of opioid overdose deaths occurring between 2001 and 2012.

RESULTS

Deaths occurred predominantly (98%) among Australians aged 15-74 years. Approximately two-thirds of the decedents (68%) were male. The heroin overdose death rate remains unchanged over the period; these were more likely to occur among males. Pharmaceutical opioid overdose deaths increased during the study period (from 21.9 per million population in 2001-36.2), and in 2012 they occurred at 2.5 times the incident rate of heroin overdose deaths. Increases in pharmaceutical opioid deaths were largely driven by accidental overdoses. They were more likely to occur among males than females, and highest among Australians aged 45-54 years. Rates of fentanyl deaths in particular showed an increase over the study period (from a very small number at the beginning of the period) but in 2012 rates of morphine deaths were higher than those for oxycodone, fentanyl and tramadol.

CONCLUSIONS

Given the increase in rates of pharmaceutical opioid overdose deaths, it is imperative to implement strategies to reduce pharmaceutical opioid-related mortality, including more restrictive prescribing practices and increasing access to treatment for opioid dependence.

Risk to heroin users of polydrug use of pregabalin or gabapentin

AIM

To examine the risk to heroin users of also using gabapentin or pregabalin (gabapentoids).

DESIGN

Multi-disciplinary study: we (a) examined trends in drug-related deaths and gabapentoid prescription data in England and Wales to test for evidence that any increase in deaths mentioning gabapentin or pregabalin is associated with trends in gabapentoid prescribing and is concomitant with opioid use; (b) interviewed people with a history of heroin use about their polydrug use involving gabapentin and pregabalin; and (c) studied the respiratory depressant effects of pregabalin in the absence and presence of morphine in mice to determine whether concomitant exposure increased the degree of respiratory depression observed.

SETTING

England and Wales.

PARTICIPANTS

Interviews were conducted with 30 participants (19 males, 11 female).

MEASUREMENTS

(a) Office of National Statistics drug-related deaths from 1 January 2004 to 31 December 2015 that mention both an opioid and pregabalin or gabapentin; (b) subjective views on the availability, use, interactions and effects of polydrug use involving pregabalin and gabapentin; and (c) rate and depth of respiration.

RESULTS

Pregabalin and gabapentin prescriptions increased approximately 24% per year from 1 million in 2004 to 10.5 million in 2015. The number of deaths involving gabapentoids increased from fewer than one per year prior to 2009 to 137 in 2015; 79% of these deaths also involved opioids. The increase in deaths was correlated highly with the increase in prescribing (correlation coefficient 0.94; 5% increase in deaths per 100 000 increase in prescriptions). Heroin users described pregabalin as easy to obtain. They suggested that the combination of heroin and pregabalin reinforced the effects of heroin but were concerned it induced 'blackouts' and increased the risk of overdose. In mice, a low dose of S-pregabalin (20 mg/kg) that did not itself depress respiration reversed tolerance to morphine depression of respiration (resulting in 35% depression of respiration, P < 0.05), whereas a high dose of S-pregabalin (200 mg/kg) alone depressed respiration and this effect summated with that of morphine.

CONCLUSIONS

For heroin users, the combination of opioids with gabapentin or pregabalin potentially increases the risk of acute overdose death through either reversal of tolerance or an additive effect of the drugs to depress respiration.

J-shaped relationship between supervised methadone consumption and retention in methadone maintenance treatment (MMT) in primary care: National cohort study

BACKGROUND

Supervised consumption ensures patients take methadone as prescribed and prevents diversion, however, the influence of supervised consumption on retention is unclear. We examined association between supervised consumption and retention across multiple treatment episodes.

METHODS

Cohort study of persons experiencing ≥1 MMT episodes in primary care (2004-2010), excluding ongoing episodes at the start of follow-up. Length of treatment episodes based on methadone prescriptions, retention classified as no interruption in prescribed methadone lasting >7 days. When a patient did not receive a new prescription within seven days after the end of coverage of a prescription, they were considered to have ceased treatment. We evaluated the relationship between supervised consumption and time to discontinuation of treatment using proportional hazards gamma frailty models to account for recurrent MMT episodes. Age, gender, median daily methadone dose, and comorbidities included as potential confounders.

RESULTS

6393 patients experienced 19,715 treatment episodes over the six-year follow-up period. A J-shaped relationship was observed; having between 20 and 60% of methadone scripts supervised (compared to <20%) associated with reduced time to discontinuation (20-39% HR=0.88, 95% CI 0.81-0.95; 40-59%: HR=0.87, 95% CI 0.81-0.94). Beyond a threshold of 60%, retention reduced (60-79% of scripts: HR=1.28, 95% CI 1.20-1.36;>80% of scripts: HR=3.59, 95% CI 3.38-3.81). Median daily dose between 60 and 120mg/per day, and multiple treatment episodes also associated with longer time to discontinuation of treatment.

CONCLUSION

A J-shaped relationship was observed between supervised consumption and retention in treatment. Additionally, patients experiencing multiple treatment episodes tend to stay in treatment for progressively longer periods of time.

Pain Management of Patients with Substance Abuse in the Ambulatory Setting

PURPOSE OF REVIEW

Abuse of illicit substances and prescription opioids is a growing problem that presents challenges for pain management in the inpatient and outpatient setting. With future patient care models shifting toward shorter hospital stays and more same-day surgeries, it is crucial that clinicians learn to manage this patient population and strike a balance between the overtreatment of pain that can subsequently worsen tolerance and addiction, and the undertreatment of pain that can lead to pseudoaddiction.

RECENT FINDINGS

Through recognition of maladaptive behaviors, use of screening programs, and pain contracts, physicians in the outpatient setting can improve their oversight and shepherding of these patients. In the inpatient setting, regularly scheduled rather than PRN opioids are recommended for chronic opioid users, and good communication with the patient's outpatient prescriber of pain medications is essential. For surgical patients on chronic opioid therapy, making a multimodal plan in advance of the day of surgery that may incorporate NSAIDs, tricyclics, gabapentinoids, anticonvulsants, opioid tapering, and regional anesthesia can help alleviate high postoperative pain control requirements. In conjunction with such medication management, setting realistic expectations for pain control with preoperative counseling may be highly beneficial. For postoperative pain refractory to other strategies, the use of inpatient low-dose ketamine infusions is a novel approach that is gaining popularity, but this does require monitoring by a dedicated pain service.

Pioglitazone attenuates the opioid withdrawal and vulnerability to relapse to heroin seeking in rodents

RATIONALE

Relapse to opioids is often driven by the avoidance of the aversive states of opioid withdrawal. We recently demonstrated that activation of peroxisome proliferator-activated receptor gamma (PPARγ) by pioglitazone reduces the motivation for heroin and attenuates its rewarding properties. However, the role of PPARγ in withdrawal and other forms of relapse to heroin is unknown.

OBJECTIVES

To further address this issue, we investigated the role of PPARγ on the development and expression of morphine withdrawal in mice and the effect of pioglitazone on several forms of heroin relapse in rats.

METHODS

We induced physical dependence to morphine in mice by injecting morphine twice daily for 6 days. Withdrawal syndrome was precipitated on day 6 with an injection of naloxone. In addition, different groups of rats were trained to self-administer heroin and, after the extinction, the relapse was elicited by cues, priming, or stress. The effect of different doses of pioglitazone was tested on these different paradigms.

RESULTS

Data show that chronic and acute administration of pioglitazone attenuates morphine withdrawal symptoms, and these effects are mediated by activation of PPARγ receptors. Activation of PPARγ by pioglitazone also abolishes yohimbine-induced reinstatement of heroin seeking and reduces heroin-induced reinstatement, while it does not affect cue-induced relapse.

CONCLUSIONS

These findings provide new insights on the role of PPARγ on opioid dependence and suggest that pioglitazone may be useful for the treatment of opioid withdrawal in opioid-addicted individuals.