The association between age of onset of opioid use and comorbidity among opioid dependent patients receiving methadone maintenance therapy

Experience of Patients With Heroin Addiction Receiving Methadone Maintenance Treatment in Community Settings in Taiwan

BACKGROUND

The World Health Organization has identified methadone maintenance therapy (MMT) as the most effective treatment for reducing patient dependence on heroin. In Taiwan, MMT has been used as a heroin harm reduction strategy since 2006. Although the effectiveness of MMT in reducing heroin addiction has been examined quantitatively in prison samples, little attention has been paid to the experiences and perspectives of patients with heroin addiction receiving MMT. This study was designed to address this gap in scientific knowledge.

PURPOSE

The aim of this study was to investigate the experiences of individuals struggling with heroin addiction who are receiving MMT in the community.

METHODS

A qualitative descriptive research approach and semistructured interviews were used in this study. We interviewed 14 participants who had received MMT in a medical center in central Taiwan. All of the interview data were recorded, transcribed, and analyzed using qualitative content analysis.

RESULTS

Four themes emerged: (a) a chance to change one's life, (b) the helpfulness of MMT, (c) a sense of being restricted and controlled, and (d) need for support.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

This article fills a gap in current scholarly understanding of patient experiences and their perspectives on the helpfulness of MMT. Understanding patient experiences and perspectives is critical to informing and developing concrete strategies for clinical practice and MMT policy. Clinical professionals should assess patient needs and concerns to determine whether they are met by current treatment programs. Policymakers should design more flexible policies to facilitate easier access by patients to methadone to reduce the risk of relapse.

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.

Pain in people seeking and receiving opioid agonist treatment: A systematic review and meta-analysis of prevalence and correlates

BACKGROUND AND AIMS

People with opioid use disorder (OUD) commonly experience pain including chronic pain. Despite the high prevalence, few studies have systematically examined the prevalence and correlates of pain among people seeking or receiving opioid agonist treatment (OAT) for OUD. This review aimed to determine the prevalence of pain in this population globally, and estimate the association between chronic pain and other demographic and clinical characteristics.

METHODS

Electronic searches were conducted in three databases (Medline, Embase and PsycINFO) from the inception until October 2022. Eligible studies reported prevalence rates of current and/or chronic pain. Meta-analyses examining the main prevalence estimates were conducted by Stata SE 18.0, and comorbid clinical conditions were analysed by Review Manager 5.4.

RESULTS

Fifty-six studies (n participants = 35 267) from sixty-seven publications were included. Prevalence estimates of current and chronic pain were reported in 27 (48.2%) and 40 studies (71.4%), respectively. Most studies were conducted in North America (71.4%, n = 40) and used cross-sectional designs (64.3%, n = 36). Meta-analyses revealed a pooled prevalence of 60.0% (95% confidence interval [CI]: 52.0-68.0) for current pain and 44.0% [95% CI: 40.0-49.0] for chronic pain. Chronic pain was positively associated with older age (mean deviation of mean age: 2.39 years, 95% CI: 1.40-3.37; I2 = 43%), unemployment (odds ratio [OR] = 0.57, 95% CI: 0.42-0.76; I2 = 78%), more severe mental health symptoms (e.g. more severe depression (standardised mean difference [SMD] of mean scores: 0.45, 95% CI: 0.20-0.70; I2 = 48%) and anxiety symptoms (SMD: 0.52, 95% CI: 0.17-0.88; I2 = 67%), and hepatitis C (OR = 1.41, 95% CI: 1.03-1.94; I2 = 0%). No association was observed between chronic pain and the onset and type of OAT, geographic location, study design, survey year, participant age or use of specific pain assessment tools.

CONCLUSIONS

There appears to be a high prevalence of pain among people seeking or receiving opioid agonist treatment for opioid use disorder compared with the general population, with positive associations for older age, unemployment, hepatitis C and the severity of some mental health symptoms.

Opioid use disorder in pediatric populations: considerations for perioperative pain management and precision opioid analgesia

INTRODUCTION

Opioids are commonly used for perioperative analgesia, yet children still suffer high rates of severe post-surgical pain and opioid-related adverse effects. Persistent and severe acute surgical pain greatly increases the child's chances of chronic surgical pain, long-term opioid use, and opioid use disorder.

AREAS COVERED

Enhanced recovery after surgery (ERAS) protocols are often inadequate in treating a child's severe surgical pain. Research suggests that 'older' and longer-acting opioids such as methadone are providing better methods to treat acute post-surgical pain. Studies indicate that lower repetitive methadone doses can decrease the incidence of chronic persistent surgical pain (CPSP). Ongoing research explores genetic components influencing severe surgical pain, inadequate opioid analgesia, and opioid use disorder. This new genetic research coupled with better utilization of opioids in the perioperative setting provides hope in personalizing surgical pain management, reducing pain, opioid use, adverse effects, and helping the fight against the opioid pandemic.

EXPERT OPINION

The opioid and analgesic pharmacogenomics approach can proactively 'tailor' a perioperative analgesic plan to each patient based on underlying polygenic risks. This transition from population-based knowledge of pain medicine to individual patient knowledge can transform acute pain medicine and greatly reduce the opioid epidemic's socioeconomic, personal, and psychological strains globally.

Association Between Opioid Use Disorder and Seizure Incidents Among Alcohol Use Disorder Patients

Many previous studies have discussed an association between alcohol use disorder (AUD) and seizure incidents. There are also case reports of seizures during opioid withdrawals. Therefore, it is possible that AUD patients may have a higher risk of seizures if they also have opioid use disorder (OUD). However, it remains unproven whether AUD patients with a dual diagnosis of OUD have higher seizure incidents, to our knowledge. This study explored seizure incidents among the patients with a dual diagnosis of AUD and OUD as well as seizures among AUD only or OUD only patients. This study utilized de-identified data from 30 777 928 hospital inpatient encounters at 948 healthcare systems over 4 years (9/1/2018-8/31/2022) from the Vizient^® Clinical Database for this study. Applying the International Classification of Diseases 10th Revision (ICD-10) diagnostic codes, AUD (1 953 575), OUD (768 982), and seizure (1 209 471) encounters were retrieved from the database to examine the effects of OUD on seizure incidence among AUD patients. This study also stratified patient encounters for demographic factors such as gender, age, and race, as well as the Vizient-categorized primary payer. Greatest gender differences were identified among AUD followed by OUD, and seizure patient groups. The mean age for seizure incidents was 57.6 years, while that of AUD was 54.7 years, and OUD 48.9 years. The greatest proportion of patients in all 3 groups were White, followed by Black, with Medicare being the most common primary payer in all 3 categories. Seizure incidents were statistically more common (P < .001, chi-square) in patients with a dual diagnosis of AUD and OUD (8.07%) compared to those with AUD only (7.55%). The patients with the dual diagnosis had a higher odd ratio than those with AUD only or OUD only. These findings across more than 900 health systems provide a greater understanding of seizure risks. Consequently, this information may help in triaging AUD and OUD patients in certain higher-risk demographic groups.

Morphine exposure during adolescence induces enduring social changes dependent on adolescent stage of exposure, sex, and social test

Drug exposure during adolescence, when the 'reward' circuitry of the brain is developing, can permanently impact reward-related behavior. Epidemiological studies show that opioid treatment during adolescence, such as pain management for a dental procedure or surgery, increases the incidence of psychiatric illness including substance use disorders. Moreover, the opioid epidemic currently in the United States is affecting younger individuals raising the impetus to understand the pathogenesis of the negative effects of opioids. One reward-related behavior that develops during adolescence is social behavior. We previously demonstrated that social development occurs in rats during sex-specific adolescent periods: early to mid-adolescence in males (postnatal day (P)30-40) and pre-early adolescence in females (P20-30). We thus hypothesized that morphine exposure during the female critical period would result in adult sociability deficits in females, but not males, and morphine administered during the male critical period would result in adult sociability deficits in males, but not females. We found that morphine exposure during the female critical period primarily resulted in deficits in sociability in females, while morphine exposure during the male critical period primarily resulted in deficits in sociability primarily in males. However, depending on the test performed and the social parameter measured, social alterations could be found in both sexes that received morphine exposure at either adolescent stage. These data indicate that when drug exposure occurs during adolescence, and how the endpoint data are measured, will play a large role in determining the effects of drug exposures on social development.

Opioid prescriptions after knee replacement: a retrospective study of pathways and prognostic factors in the Swiss healthcare setting

OBJECTIVES

The optimal use of opioids after knee replacement (KR) remains to be determined, given the growing evidence that opioids are no more effective than other analgesics and that their adverse effects can impair quality of life. Therefore, the objective is to examine opioid prescriptions after KR.

DESIGN

In this retrospective study, we used descriptive statistics and estimated the association of prognostic factors using generalised negative binomial models.

SETTING

The study is based on anonymised claims data of patients with mandatory health insurance at Helsana, a leading Swiss health insurance.

PARTICIPANTS

Overall, 9122 patients undergoing KR between 2015 and 2018 were identified.

PRIMARY AND SECONDARY OUTCOME MEASURES

Based on reimbursed bills, we calculated the dosage (morphine equivalent dose, MED) and the episode length (acute: <90 days; subacute: ≥90 to <120 days or <10 claims; chronic: ≥90 days and ≥10 claims or ≥120 days). The incidence rate ratios (IRRs) for postoperative opioids were calculated.

RESULTS

Of all patients, 3445 (37.8%) received opioids in the postoperative year. A large majority had acute episodes (3067, 89.0%), 2211 (65.0%) had peak MED levels above 100 mg/day and most patients received opioids in the first 10 postoperative weeks (2881, 31.6%). Increasing age (66-75 and >75 vs 18-65) was associated with decreased IRR (0.776 (95% CI 0.7 to 0.859); 0.723 (95% CI 0.649 to 0.805)), whereas preoperative non-opioid analgesics and opioids were associated with higher IRR (1.271 (95% CI 1.155 to 1.399); 3.977 (95% CI 4.409 to 3.591)).

CONCLUSION

The high opioid demand is unexpected given that current recommendations advise using opioids only when other pain therapies are ineffective. To ensure medication safety, it is important to consider alternative treatment options and ensure that benefits outweigh potential risks.

Prenatal heroin exposure alters brain morphology and connectivity in adolescent mice

The United States is experiencing a dramatic increase in maternal opioid misuse and, consequently, the number of individuals exposed to opioids in utero. Prenatal opioid exposure has both acute and long-lasting effects on health and wellbeing. Effects on the brain, often identified at school age, manifest as cognitive impairment, attention deficit, and reduced scholastic achievement. The neurobiological basis for these effects is poorly understood. Here, we examine how in utero exposure to heroin affects brain development into early adolescence in a mouse model. Pregnant C57BL/6J mice received escalating doses of heroin twice daily on gestational days 4-18. The brains of offspring were assessed on postnatal day 28 using 9.4 T diffusion MRI of postmortem specimens at 36 μm resolution. Whole-brain volumes and the volumes of 166 bilateral regions were compared between heroin-exposed and control offspring. We identified a reduction in whole-brain volume in heroin-exposed offspring and heroin-associated volume changes in 29 regions after standardizing for whole-brain volume. Regions with bilaterally reduced standardized volumes in heroin-exposed offspring relative to controls include the ectorhinal and insular cortices. Regions with bilaterally increased standardized volumes in heroin-exposed offspring relative to controls include the periaqueductal gray, septal region, striatum, and hypothalamus. Leveraging microscopic resolution diffusion tensor imaging and precise regional parcellation, we generated whole-brain structural MRI diffusion connectomes. Using a dimension reduction approach with multivariate analysis of variance to assess group differences in the connectome, we found that in utero heroin exposure altered structure-based connectivity of the left septal region and the region that acts as a hub for limbic regulatory actions. Consistent with clinical evidence, our findings suggest that prenatal opioid exposure may have effects on brain morphology, connectivity, and, consequently, function that persist into adolescence. This work expands our understanding of the risks associated with opioid misuse during pregnancy and identifies biomarkers that may facilitate diagnosis and treatment.

The effects of childhood trauma and mental disorders on treatment engagement, contact with the criminal justice system, and mortality among people with opioid dependence

BACKGROUND

Childhood trauma and mental disorders increase the risk of opioid dependence. We aimed to examine whether childhood trauma and mental disorders are associated with opioid agonist treatment (OAT) engagement, contact with the criminal justice system, and mortality among people with opioid dependence.

METHODS

This observational study linked survey data from 1482 people receiving OAT in Sydney, Australia (2004-2008) to administrative data on OAT, crime, and mortality through 2017. We used survey data to assess childhood trauma, depression, panic disorder, post-traumatic stress disorder (PTSD), borderline personality disorder, anti-social personality disorder (ASPD), and comorbid substance dependence. We used discrete-time analysis to examine time from opioid dependence onset to OAT entry and mortality. Poisson regressions were used to analyze time receiving OAT and number of charges.

RESULTS

Participants with extensive childhood trauma histories and ASPD were less likely to enter OAT and those with depression were more likely to enter OAT in any given year after opioid dependence onset. Panic disorder, PTSD, and borderline personality disorder were associated with less time in OAT. Extensive histories of childhood trauma, PTSD, ASPD, and comorbid substance dependence increased risk of charges for any offence. There were no significant associations between the exposure variables and mortality.

CONCLUSIONS

Our findings suggest that childhood trauma and mental disorders increase the risk of adverse treatment and social outcomes among people with opioid dependence. Interventions that aim to reduce harm among people with opioid dependence may consider the effect of childhood trauma and mental disorders on OAT engagement and crime.

De-implementing opioid prescribing in a dental group practice: Lessons learned

BACKGROUND

Drug overdose has become a leading cause of accidental death in the United States. Between 2000 and 2015, the rate of deaths from drug overdoses increased 137%, including a 200% increase in the rate of overdose deaths involving opioids (including opioid pain relievers and heroin). Unnecessary opioid prescribing is one of the factors driving this epidemic.

OBJECTIVES

The primary objective of this paper is to share lessons learned while conducting a randomized trial to de-implement opioids for post-extraction pain management utilizing clinical decision support (CDS) with and without patient education. The lessons learned from conducting this trial in a real-world setting can be applied to future dissemination and implementation oral health research.

METHODS

The sources informing lessons learned were generated from qualitative interviews conducted with 20 of the forty-nine dental providers involved in the study following the implementation phase of the trial. Ongoing policy, social and environmental factors were tracked throughout the study.

RESULTS

Dental providers in the trial identified the impact of training that involved health professionals sharing information about the personal impact of pain and opioid use. Additionally, they found utility in being presented with a dashboard detailing their prescribing patterns related to other dentists. For the 30 general dentists with access to the CDS, use of its portal varied widely, with most using it 10%-49% of the time related to extractions.

CONCLUSIONS

In the context of a downward trend in opioid prescribing and considering the influence of the COVID pandemic during the trial, dental providers indicated benefit in training about negative personal impacts of prescribing opioids, and personally relevant feedback about their prescribing patterns. Only modest use of the CDS was realized. Implementation of this trial was impacted by governmental and health system policies and the COVID pandemic, prompt the consideration of implications regarding continuing ways to limit opioid prescribing among dental providers.

Mu Opioid Receptor Dynamics in Healthy Volunteers with a History of Childhood Maltreatment

Evidence suggests that adults with a history of childhood maltreatment, the experience of emotional or physical neglect and/or abuse within the family during childhood, have blunted reward and stress processing, and higher risk of depression. The mu opioid receptor rich nucleus accumbens and amygdala are critical to reward and stress processing respectively. We hypothesized that nucleus accumbens and amygdala mu opioid receptor densities and activity (change in receptor binding due to endogenous opioid release or receptor conformation change) were negatively associated with childhood maltreatment in healthy young adults. Maltreatment was assessed with the Childhood Trauma Questionnaire (CTQ). Healthy participants, n = 75 (52% female) completed [11C]carfentanil positron emission tomography imaging labeling mu opioid receptors. The relationship between CTQ score and binding potential (BPND, proportional to density of unoccupied receptors) was evaluated with a linear mixed effects model. No significant relationship was found between CTQ score and BPND (f = 3.28; df = 1, 73; p = 0.074) or change in BPND (activity) (t = 1.48; df = 198.3; p = 0.14). This is the first investigation of mu opioid receptors in those with childhood maltreatment. We did not identify a significant relationship between mu opioid receptor dynamics and severity of maltreatment in those without psychopathology. Because this cohort has a low CTQ score average, this may indicate that those with low severity of maltreatment may not have associated changes in mu opioid receptor dynamics. Future directions include evaluating a cohort with increased severity of childhood maltreatment.

Psychiatric Comorbidity, Psychosocial Problems, and Functioning of People Who Inject Opioids: An Observational Study

Background

Injecting drug use (IDU) is a growing concern in India. This problem may coexist with other psychiatric disorders. The psychiatric comorbidity in IDUrs affects the psychosocial functioning of this population. This study aimed to assess psychiatric comorbidities, psychosocial problems, and global functioning of people who inject opioids.

Methods

This cross-sectional study included opioid-dependent individuals with a history of injecting opioids who visited an outpatient clinic for buprenorphine maintenance treatment. The patients were assessed by SCID-I and SCID-II for Axis-I and Axis-II psychiatric disorders, respectively. The diagnosis was confirmed according to DSM-IV-TR. Moreover, the assessment of psychosocial and environmental problems was done according to Axis-IV of DSM-IV. Functioning was assessed using the Global Assessment of Functioning Scale (GAF). Substance use severity was also assessed using Addiction Severity Index (ASI).

Findings

A total of 100 participants were included in the study. All participants were male, and the majority (63%) were in the age range of 18-40 years with the mean age of 36.96 (SD=10.12). Moreover, 76% of the participants had psychiatric comorbidity. Mood disorder (28.95%), anxiety disorder (13.16%), any personality disorder (27.63%) were the most common comorbidities. The results also revealed psychosocial and environmental problems were significantly higher in participants with comorbidity and their global functioning was poor.

Conclusion

Psychiatric comorbidities are quite common and are associated with various psychosocial and environmental problems. Early identification and interventions for comorbid conditions along with community-based psychosocial rehabilitation should be considered for better outcomes.

Patient characteristics associated with initiation of XR-naltrexone for opioid use disorder in clinical trials

BACKGROUND

Extended-release injectable naltrexone (XR-naltrexone) is effective for treatment of patients with opioid use disorder (OUD), but initiation remains a barrier due to the challenge of tolerating opioid withdrawal prior to administration. Understanding factors associated with successful initiation of XR-naltrexone could facilitate its implementation through patient-treatment matching.

METHODS

We combined data from five consecutive studies that sought to initiate patients with active opioid use onto XR-naltrexone using a rapid procedure consisting of minimal buprenorphine, non-opioid medications for treating opioid withdrawal, and ascending low doses of oral naltrexone. Associations between patient characteristics and initiating naltrexone were estimated with logistic regression models. To evaluate whether associations differed between inpatient and outpatient settings, patient characteristic-by-setting interactions were also estimated.

RESULTS

409 patients were included in the analyses and 228 (56%) received the first injection. A significantly greater percent of inpatients (62%) vs outpatients (48%) initiated XR-naltrexone. Initiation success was significantly more likely on an inpatient basis for heroin (60.9% inpatient vs 36.2% outpatient), intravenous (56.3% inpatient vs 22.5% outpatient), and speedball users (68.1% inpatient vs 32.3% outpatient). Prescription opioid users showed similar, higher initiation rates across settings (68.9% inpatient; 73.7% outpatient).

CONCLUSIONS

An inpatient setting may be the preferred strategy for rapid initiation of XR-naltrexone for opioid users with greater severity, including heroin or speedball injection users or those who use opioids intravenously. Initiation on an outpatient basis may be more likely to succeed for prescription opioid users.

Telehealth-Based Delivery of Medication-Assisted Treatment for Opioid Use Disorder: a Critical Review of Recent Developments

PURPOSE OF REVIEW

Telehealth-delivered medication-assisted treatment for opioid use disorder (tele-MOUD) has received increased attention, with the intersection of the opioid epidemic and COVID-19 pandemic, but research on recent developments is scattered. We critically review recent literature on tele-MOUD and synthesize studies reporting primary data under four themes: clinical effectiveness, non-clinical effectiveness, perceptions, and regulatory considerations.

RECENT FINDINGS

Despite increasing publications, most failed to include long-term comprehensive assessments. Findings indicate favorable outcomes such as improvements in retention and abstinence rates, positive experiences, and improved feasibility with the relaxation of regulatory measures. With increased adoption, clinician and patient perceptions appeared largely positive. Negative findings, albeit minor, were primarily associated with workflow adaptation difficulties and limited access of underserved populations to technology and internet connection. Additional financial, logistical, outreach, and training support for clinicians, patients, and support staff is recommended, in addition to permanent evidence-based regulatory reforms, to scale and optimize tele-MOUD services. Comprehensive recommendations to overcome limitations are expanded therein.

Patient, Provider Type, and Procedure Type Factors Associated with Opioid Prescribing by Dentists in a Health Care System

Introduction

Reports examining opioid prescribing for dental conditions are limited and do not examine patient-level factors. This study examines the association of patient age, sex, race, ethnicity, Medicaid coverage, and the need for an interpreter in addition to procedure type and dental provider type with receipt of an opioid prescription in dental care settings within a large health system.

Materials and Methods

This study was conducted utilizing data from the electronic health record of HealthPartners, a large dental practice embedded within a health care system. The analytic sample consisted of all 169,173 encounters from 90,487 patients undergoing a dental procedure in the baseline period (9/1/2018 to 8/30/2019), prior to implementing a clinical trial to de-implement opioids in dentistry.

Results

Opioids were prescribed at 1.9% of all 169,173 encounters and rates varied by patient factors, procedure category, and provider type. Opioid prescriptions were most likely for extraction encounters (25.9%). In a multivariable analysis of 8760 extraction encounters, all patient age groups were more likely than those age 66+ to receive an opioid prescription, particularly those age 18–25 (OR=6.94). Patients having a complex rather than simple extraction were more likely to receive an opioid prescription (OR=6.31) and those seen by an oral surgeon rather than a general dentist (OR=9.11) were more likely to receive an opioid prescription. Among 108,748 encounters with a diagnostic procedure, opioid prescribing was more likely among male than female patients (OR=1.20), Black patients relative to White (OR=1.69), patients with Medicaid coverage (OR=1.86), and patients seeing an oral surgeon rather than a general dentist (OR=27.81).

Conclusion

Opioid prescribing rates vary considerably depending on procedure type. Patterns of associations between patient factors and opioid prescribing also vary considerably across procedure type. To understand which patient groups are more at risk of being prescribed opioids, it is essential to consider the procedures they are receiving.

The association between opioids, environmental, demographic, and socioeconomic indicators and COVID-19 mortality rates in the United States: an ecological study at the county level

Background

The spread of the COVID-19 pandemic throughout the world presents an unprecedented challenge to public health inequities. People who use opioids may be a vulnerable group disproportionately impacted by the current pandemic, however, the limited prior research in this area makes it unclear whether COVID-19 and opioid use outcomes may be related, and whether other environmental and socioeconomic factors might play a role in explaining COVID-19 mortality. The objective of this study is to evaluate the association between opioid-related mortality and COVID-19 mortality across U.S. counties.

Methods

Data from 3142 counties across the U.S. were used to model the cumulative count of deaths due to COVID-19 up to June 2, 2020. A multivariable negative-binomial regression model was employed to evaluate the adjusted COVID-19 mortality rate ratios (aMRR).

Results

After controlling for covariates, counties with higher rates of opioid-related mortality per 100,000 persons were found to be significantly associated with higher rates of COVID-19 mortality (aMRR: 1.0134; 95% CI [1.0054, 1.0214]; P = 0.001). Counties with higher average daily Particulate Matter (PM2.5) exposure also saw significantly higher rates of COVID-19 mortality. Analyses revealed rural counties, counties with higher percentages of non-Hispanic whites, and counties with increased average maximum temperatures are significantly associated with lower mortality rates from COVID-19.

Conclusions

This study indicates need for public health efforts in hard hit COVID-19 regions to also focus prevention efforts on overdose risk among people who use opioids. Future studies using individual-level data are needed to allow for detailed inferences.

Association study of Catechol-o-methyltransferase and Alpha-1-adrenergic receptor gene polymorphisms with multiple phenotypes of heroin use disorder

Heroin use disorder is a chronic relapsing brain disease containing multiple phenotypes. These phenotypes vary among heroin users and might be influenced by genetic factors. Single-nucleotide polymorphisms (SNPs) of catechol-O-methyltransferase (COMT) and alpha-1-adrenergic receptor (ADRA1A) genes are associated with heroin use disorder. However, it has not been clarified which phenotypes of heroin use disorder are related to these genes. To address this question, we recruited 801 unrelated heroin users and divided them into different subgroups according to four important phenotypes of heroin use disorder. Then 7 SNPs in the functional region of these genes were systematically screened and genotyped using a SNaPshot assay. We found that the A allele of ADRA1A rs1048101 was associated with a shorter duration of transition from first use to addiction. Subjects with the C allele of ADRA1A rs3808585 were more susceptible to memory impairment after heroin use disorder. Subjects with the G allele of COMT rs769224 were more likely to take a higher dose of heroin every day. Our study confirmed the association between polymorphisms of COMT and ADRA1A with those specific phenotypes of heroin use disorder, which will be instructive for the precise treatment of the disease.

Factors Associated with Sustained Remission among Chronic Opioid Users

Background

Chronic opioid use is a major public health problem with significant morbidity. The aim of this study was to investigate factors associated with sustained remission among a sample of Iranian chronic opioid users in Shiraz, Iran.

Methods

This was a cross-sectional study to evaluate sustained remission among chronic opiate users aged 20-60 years. Participants included two groups: 365 people who have been in sustained remission for the past year, and 187 persons who did not achieve remission for the past one year. Then, demographic and factors related to drug use pattern and previous treatments were compared between two groups. Pearson chi-square test was used for univariate analysis and backward stepwise logistic regression was used to estimate adjusted odds ratios (AORs).

Findings

Our findings showed that sustained remission was associated with Narcotic Anonymous (NA) participation [AOR = 3.28, 95% confidence interval (CI): 2.19-4.89, P < 0.001], male gender (AOR = 2.53, 95% CI: 1.45-4.43, P = 0.001), younger age of onset (AOR = 1.63, 95% CI: 1.03-2.58, P = 0.037), higher total years of opioid use (AOR = 2.13, 95% CI: 1.42-3.19, P < 0.001), no history of imprisonment (AOR = 2.11, 95% CI: 1.16-3.85, P = 0.015), and family support (AOR = 2.58, 95% CI: 1.33-5.01, P = 0.005).

Conclusion

Participation in self-help groups can be a suitable alternative in predicting sustained remission among chronic opiate users. Chronic opioid users should be encouraged by the physicians who are involved in the treatment of drug addiction to participate in NA programs.

Rapid transition from methadone to buprenorphine using naltrexone-induced withdrawal: A case report

Background: Patients taking methadone for opioid use disorder may desire transition to buprenorphine for a number of reasons. However, the current recommended approach for this transition generally takes weeks to months as an outpatient, causing considerable discomfort to the patient and a heightened risk of relapse during the transition period. Case: We describe the case of a patient on methadone maintenance who was rapidly transitioned to buprenorphine because of her desire to not return to her methadone clinic. In order to rapidly transition the patient from methadone to buprenorphine, naltrexone was administered to precipitate acute opioid withdrawal, which was followed soon after by buprenorphine induction. Discussion: Rapid transition from methadone maintenance to buprenorphine can be accomplished in inpatients by precipitating acute withdrawal with naltrexone, providing an effective alternative for patients who cannot tolerate the typical protracted methadone taper required prior to buprenorphine induction as an outpatient.

Liver damage indices as a tool for modifying methadone maintenance treatment: a cross-sectional study

Aim

To assess the effect of liver damage on methadone metabolism in opiate addicts undergoing methadone maintenance treatment (MMT).

Methods

This cross-sectional study recruited 74 patients treated at the outpatient clinic of Public Health Institute of Split-Dalmatia County from 2013-2016. Concentrations of methadone and its main inactive metabolite were measured in participants’ biological samples on regular check-ups. Urine samples obtained before oral methadone intake, and blood and urine samples obtained 90 minutes after methadone intake were analyzed using gas chromatography/mass spectrometry. Participants were divided into groups according to liver damage criteria: hepatitis C virus status (positive, negative, or clinical remission); aspartate aminotransferase to platelet ratio (APRI) index (<0.7 and ≥0.7); and fibrosis-4 score (<1.45, 1.45-3.25, >3.25).

Results

Metabolic ratio and methadone metabolite concentration in plasma decreased linearly with HCV infection status by the factor of 1.67 (P = 0.001) and 2.2 (P = 0.043), respectively. Metabolic ratio in plasma decreased in patients with APRI index ≥0.7 by the average factor of 2.12 (P = 0.01) and methadone metabolite concentration in plasma decreased by the factor of 6.16 (P = 0.009). Metabolic ratio in urine decreased with the severity of fibrosis-4 score by the average factor of 1.63 (P = 0.008), whereas methadone metabolite concentration decreased by the factor of 3.53 (P = 0.007).

Conclusion

Liver damage decreases methadone metabolism. Indices of liver function should be calculated regularly during MMT for methadone dose titration.

Pharmacological Strategies for Decreasing Opioid Therapy and Management of Side Effects from Chronic Use

As awareness increases about the side effects of opioids and risks of misuse, opioid use and appropriate weaning of opioid therapies have become topics of significant clinical relevance among pediatric populations. Critically ill hospitalized neonates, children, and adolescents routinely receive opioids for analgesia and sedation as part of their hospitalization, for both acute and chronic illnesses. Opioids are frequently administered to manage pain symptoms, reduce anxiety and agitation, and diminish physiological stress responses. Opioids are also regularly prescribed to youth with chronic pain. These medications may be prescribed during the initial phase of a diagnostic workup, during an emergency room visit; as an inpatient, or on an outpatient basis. Following treatment for underlying pain conditions, it can be challenging to appropriately wean and discontinue opioid therapies. Weaning opioid therapy requires special expertise and care to avoid symptoms of increased pain, withdrawal, and agitation. To address this challenge, there have been enhanced efforts to implement opioid-reduction during pharmacological therapies for pediatric pain management. Effective pain management therapies and their outcomes in pediatrics are outside the scope of this paper. The aims of this paper were to: (1) Review the current practice of opioid-reduction during pharmacological therapies; and (2) highlight concrete opioid weaning strategies and management of opioid withdrawal.

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.

Generational trends and patterns in readmission within a statewide cohort of clients receiving heroin use disorder treatment in Maryland, 2007-2013

The recent rise in opioid-related overdose deaths stresses the importance of understanding how heroin use disorders persist and what interventions are best suited for treating these illnesses. Trends show that there are diverse pathways leading to heroin use disorder that span multiple generations, but little is known about how different generations utilize and respond to treatment. This study provides insight into treatment utilization for young, middle-aged, and older adults by examination of an unusually rich longitudinal dataset of substance use disorder clients in Maryland who were treated for heroin use. Results show that clear patterns of treatment readmission emerge across generations in treatment-naïve clients with regard to gender, ethnicity, employment, geographical region, and treatment type/intensity. In particular, Millennials comprise the majority of the clients receiving heroin use disorder treatment and are the largest contributor to these readmission patterns. Millennials are also given opioid maintenance therapy (OMT) more frequently than other generations, while exhibiting a strong avoidance to treatment. Generational differences in treatment decisions and outcomes over the course of a treatment career are important for understanding the nature of the current opioid epidemic, and can play an important role in directing heroin use disorder treatment efforts and improving models of care.

Social-demographic shift in drug users at the first-ever- methadone maintenance treatment in Wuhan, China

The methadone maintenance treatment (MMT) has been initiated in Wuhan, China since early 2006. To understand the social-demographic, behavioral, and infectious diseases characteristics of drug users enrolled in their first-ever-MMT between 2006 and 2015, a retrospective observational study was implemented to also provide evidence for health policy-decisions to reduce harm and control disease. Pearson chi-square tests and t-tests were used to assess significant differences between two 5-year periods, 2006-2010 and 2011-2015. We observed increases in the mean age (38.65 vs. 42.43 years, P < 0.001), mean age of initial opioid drug use (28.18 vs. 31.07 years, P < 0.001), employment (11.9% vs. 30.7%, P < 0.001), married/co-habiting (42.4% vs. 47.8%, P < 0.001), and declines in higher education level (93.6% vs. 84.8%, P < 0.001), injection (82.3% vs. 75.1%, P < 0.001), syringe sharing (27.7% vs. 9.9%, P < 0.001), HCV infection rates (72.9% vs. 70.5%, P = 0.017). The number of drug users enrolling each year reduced following a continuous rapid growth in the first 3 years. The findings imply for adjusting in treatment services and allocation of resources to respond to emerging trends. In addition, the data will also be helpful for identifying needs and getting a baseline insight of the social-demographic and behavioral characteristics of the opioid abusers in the area.

Association between Tooth Loss and Opium Addiction: Results of a Community-Based Study on 5900 Adult Individuals in South East of Iran in 2015

BACKGROUND

Like any other drug abuse, opium use is known to have detrimental effects on oral health. Oral hygiene neglect in opium users can lead to tooth loss resulting in further functional, esthetic, and dieting problems. Therefore, the aim of this study was to assess the association between tooth loss and opium addiction in a large-scale population.

MATERIALS AND METHODS

This study was part of an extensive study related to the risk factors of cardiovascular disease and conducted by the center for physiological research during 2012-2015 in Kerman. A total of 5900, 15-75-year-old individuals, were recruited by a single-stage random cluster sampling method. Factors including opium and smoking consumption, factors related to oral health, hygiene, and the number of missing teeth were examined. Data were collected through questionnaires, interviews, and physical examination.

RESULTS

Of 5900 individuals, 2662 (45.1%) were men and the rest were women, which 1011 individuals (17.1%) consumed opium. The prevalence of opium abuse was significantly higher in men. Regarding the oral dental indicators, the numbers of missing teeth (P < 0.001), decayed (P = 0.01), and the total index of decayed, missing, and filled teeth (P < 0.001) were significantly higher in addicts as compared to nonaddicts. The gingival index and community periodontal index scores were significantly lower in addicts. Addicted women had a higher prevalence of tooth loss.

CONCLUSIONS

Opium addiction is associated with higher tooth loss, especially, in women opium users. Dental practitioners and health politicians should pay special attention to the oral health of addicts before tooth loss occurs.