Opioid substitution treatment and heroin dependent adolescents: reductions in heroin use and treatment retention over twelve months

Assessment of treatment retention rates and predictors of retention on opioid agonist treatment among adolescents

INTRODUCTION

Opioid agonist treatment (OAT) is an effective treatment for opioid dependence syndrome in adults. However, studies on effectiveness of OAT in adolescents are limited; existing studies show varying retention rates. The present study aimed to assess OAT retention rates in adolescent patients with opioid dependence syndrome registered in a community drug treatment clinic in Delhi, India, and to analyse factors associated with retention at 1 year.

METHODS

Retrospective cohort study. All adolescents (n = 130) aged 10-19 years, started on OAT from January 2020 to July 2022 were included. Baseline and follow-up data was extracted from online record system maintained at the clinic. OAT retention rates at different timepoints were assessed. Multivariable logistic regression was used to discern factors associated with one-year retention.

RESULTS

The participants' mean age was 16.9 (SD 1.4) years. Mean age of starting opioids was 14.9 (SD 2.2) years; 29.5% (n = 38) injected opioids. The 6-, 12-, 18- and 24-month retention rate on OAT was 64.4%, 45.6%, 38.7% and 29% respectively. The retention rates with buprenorphine and methadone were comparable. Multivariate logistic regression showed retention for less than 12 months to be significantly associated with younger age of starting heroin, involvement in illegal activities, absenteeism from school and substance use in family.

DISCUSSION AND CONCLUSIONS

The 12-month retention rates on OAT in adolescents is comparable to retention rates in adults. Various factors associated with early age of onset of opioid use are also associated with lower retention rates on OAT.

Goofballing of Opioid and Methamphetamine: The Science Behind the Deadly Cocktail

Globally, millions of people suffer from various substance use disorders (SUD), including mono-and polydrug use of opioids and methamphetamine. Brain regions such as the cingulate cortex, infralimbic cortex, dorsal striatum, nucleus accumbens, basolateral and central amygdala have been shown to play important roles in addiction-related behavioral changes. Clinical and pre-clinical studies have characterized these brain regions and their corresponding neurochemical changes in numerous phases of drug dependence such as acute drug use, intoxication, craving, withdrawal, and relapse. At present, many studies have reported the individual effects of opioids and methamphetamine. However, little is known about their combined effects. Co-use of these drugs produces effects greater than either drug alone, where one decreases the side effects of the other, and the combination produces a prolonged intoxication period or a more desirable intoxication effect. An increasing number of studies have associated polydrug abuse with poorer treatment outcomes, drug-related deaths, and more severe psychopathologies. To date, the pharmacological treatment efficacy for polydrug abuse is vague, and still at the experimental stage. This present review discusses the human and animal behavioral, neuroanatomical, and neurochemical changes underlying both morphine and methamphetamine dependence separately, as well as its combination. This narrative review also delineates the recent advances in the pharmacotherapy of mono- and poly drug-use of opioids and methamphetamine at clinical and preclinical stages.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Opioid use disorder: a neglected human immunodeficiency virus risk in American adolescents

In 2017 alone, 783 000 children aged 12-17 years misused opioids with 14 000 using heroin. Opioid misuse and opioid use disorder (OUD) in adolescents and young adults are significant barriers to ending the HIV epidemic. To address these synergistic scourges requires dedicated practitioners and improved access to life-saving evidence-based treatment. Adolescents and young adults make up over one in five new HIV diagnoses even though they are less likely to be tested or know they are infected. Adolescents and young adults living with HIV are less likely to be retained in care or achieve virological suppression. OUD further leads to increased rates of risky behaviours (like sex without condoms), deceased retention in HIV care and decreased rates of viral suppression in this vulnerable population. Medications for opioid use disorder (MOUD) are recommended for adolescents and young adults with severe OUD and help retain youth in HIV treatment and decrease risk of death. However, due to stigma and lack of experience prescribing MOUD in adolescents, MOUD is often perceived as a last line option. MOUD remains difficult to access for adolescents with a shortage of providers and decreased options for treatment as compared to adults. Addiction treatment is infection prevention, and integrated addiction and HIV services are recommended to improve health outcomes. A multipronged approach including patient education, provider training and policy changes to improve access to treatment and harm reduction are urgently needed confront the drug use epidemic in youth.

The impact of methamphetamine/amphetamine use on receipt and outcomes of medications for opioid use disorder: a systematic review

Background

Methamphetamine/amphetamine use has sharply increased among people with opioid use disorder (OUD). It is therefore important to understand whether and how use of these substances may impact receipt of, and outcomes associated with, medications for OUD (MOUD). This systematic review identified studies that examined associations between methamphetamine/amphetamine use or use disorder and 3 classes of outcomes: (1) receipt of MOUD, (2) retention in MOUD, and (3) opioid abstinence during MOUD.

Methods

We searched 3 databases (PubMed/MEDLINE, PsycINFO, CINAHL Complete) from 1/1/2000 to 7/28/2020 using key words and subject headings, and hand-searched reference lists of included articles. English-language studies of people with documented OUD/opioid use that reported a quantitative association between methamphetamine/amphetamine use or use disorder and an outcome of interest were included. Study data were extracted using a standardized template, and risk of bias was assessed for each study. Screening, inclusion, data extraction and bias assessment were conducted independently by 2 authors. Study characteristics and findings were summarized for each class of outcomes.

Results

Thirty-nine studies met inclusion criteria. Studies generally found that methamphetamine/amphetamine use or use disorder was negatively associated with receiving methadone and buprenorphine; 2 studies suggested positive associations with receiving naltrexone. Studies generally found negative associations with retention; most studies finding no association had small samples, and these studies tended to examine shorter retention timeframes and describe provision of adjunctive services to address substance use. Studies generally found negative associations with opioid abstinence during treatment among patients receiving methadone or sustained-release naltrexone implants, though observed associations may have been confounded by other polysubstance use. Most studies examining opioid abstinence during other types of MOUD treatment had small samples.

Conclusions

Overall, existing research suggests people who use methamphetamine/amphetamines may have lower receipt of MOUD, retention in MOUD, and opioid abstinence during MOUD. Future research should examine how specific policies and treatment models impact MOUD outcomes for these patients, and seek to understand the perspectives of MOUD providers and people who use both opioids and methamphetamine/amphetamines. Efforts to improve MOUD care and overdose prevention strategies are needed for this population.

The cascade of care for opioid use disorder among youth in British Columbia, 2018

BACKGROUND

Medication for opioid use disorder (MOUD) is associated with substantial reductions in the risk of mortality, and American and Canadian guidelines recommend it as part of the full range of available treatments for youth with opioid use disorder (OUD). We estimated the OUD cascade of care for all adolescents (ages 12-18) and young adults (19-24) with OUD in British Columbia, Canada (BC) in 2018.

METHODS

Using a provincial-level linkage of six health administrative databases, we classified youth with OUD as adolescents (ages 12-18) or young adults (19-24) to compare with older adults (≥25) and described key factors known to influence engagement in health care. The eight-stage cascade of care included diagnosed with OUD, ever engaged in MOUD, recently in MOUD, currently in MOUD, and retained in MOUD for ≥1 month, ≥3 months, ≥12 months, ≥24 months.

RESULTS

We identified 4048 youth diagnosed with OUD as of September 30, 2018 (6.3% of all people with OUD). Most were young adults, aged 19-24 (n = 3602; 89.0% of all youth), a majority of whom were males (n = 1984; 55.1%). In contrast, adolescents diagnosed with OUD (n = 446; 11.0% of all youth) were mostly females (n = 287; 64.4%). Compared to adolescents, there were more young adults diagnosed with OUD ever engaged in MOUD (71.4% v. 36.5%), currently on MOUD (29.3% v. 16.8%), and retained in care for ≥1 year (8.6% v. 2.0%).

CONCLUSIONS

A high proportion of youth aged 12-24 diagnosed with OUD in a health care setting in British Columbia received MOUD yet continued engagement is infrequent, particularly for adolescents. Long-term treatment plans for youth need to consider including MOUD when appropriate as part of tailored, youth-friendly services.

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

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

Using Modern Neuroscience to Inform Opioid Use and Abuse Liability in Adolescents

Opioid abuse and overdosing have reached epidemic status in the United States, and this epidemic has profound negative effects on the lives of adolescents and their families. A combination of readily available opioids (including illicit opioids, such as heroin, and overprescribed prescription opioid-based painkillers) and an abuse vulnerability inherent to adolescence drives the problem. The pharmacology of opioids in the context of adolescent brain neurobiology helps explain the enhanced vulnerability to drug abuse experienced by the young. This report overviews these topics as they relate to orthopaedic procedures employed for adolescent patients.

Barriers to progressing through a methadone maintenance treatment programme: perspectives of the clients in the Mid-West of Ireland's drug and alcohol services

Background

The ‘perfect’ journey through an Irish Methadone Maintenance Treatment Programme (MMTP) would have a client engage appropriately with all relevant services available to them, inclusive of psychiatry, counselling, out-reach support, nursing and psychology. Concurrently, a client would ideally adhere to their prescribed methadone-dosing regimen, until a client is stabilised allowing them to function optimally. At this point, a client should transfer to the GP community setting. Unfortunately, this fails to occur. To date, very few studies have specifically investigated the reasons why a cohort of clients remain ‘trapped’ in the high risk, specialist clinical setting.

Methods

Qualitative detailed semi-structured interviews were undertaken with 17 clients of one of Ireland’s Health Service Executive (HSE) Drug and Alcohol Services, entitled ‘HSE Mid-West Limerick Drug and Alcohol Service’. Each client had a severe Opioid Use Disorder (OUD) and clients had spent on average 7.5 years engaging with the MMTP.

Results

Participants’ life journey prior to an OUD included Adverse Childhood Experiences (ACEs) and early exposure to illicit drug use. Shared life events resulting in their initiating and sustaining an OUD involved continuous hardship into adulthood, mental illness and concurrent benzodiazepine use disorder, often resulting in harrowing accounts of participants’ loneliness and lack of life purpose. Their living environments, an erroneous understanding of their illness and poor communication with allied health professionals further perpetuated their OUD. Positive factors influencing periods of abstinence were familial incentives and a belief in the efficacy of methadone. Clients own suggestions for improving their journeys included employing a multi-sectorial approach to managing OUD and educating themselves and others on opioid agonist treatments. If clients were not progressing appropriately, they themselves suggested enforcing a ‘time-limit’ on clients to engage with the programme or indeed for their treatment to be postponed.

Conclusions

To optimise the functioning of the MMTP, three tasks need to be fulfilled: 1) Reduce the incidences of ACEs, 2) Diagnose and treat clients with a dual diagnosis 3) Educate clients, their families, the public and allied health care professionals on all aspects of OUD. A cross- departmental, inter-governmental approach is needed to address opioid misuse as a societal issue as a whole.