Substance use, health and social problems of service users at 54 drug treatment agencies. Intake data from the National Treatment Outcome Research Study

The Association between a MAOB Variable Number Tandem Repeat Polymorphism and Cocaine and Opiate Addictions in Polyconsumers

Genetic analysis of the association between alcohol, cocaine, and opiate addiction and variable number tandem repeat (VNTR) polymorphisms in monoamine oxidase B (MAOB) and serotonergic 5-hydroxytryptamine (serotonin) receptor 1B and 2C (HTR1B 21 and HTR2C) pathway genes was performed in a sample of 302 polyconsumers. Our genetic association analysis revealed a significant association between a 184 base pair (bp) VNTR polymorphism in the MAOB gene and addiction to cocaine and opiates. This work highlights new genetic marker associations in cocaine and opiate polyconsumer addictions. These data help to clarify and quantify the complex role of genetics in addictive disorders, as well as their future contribution to the prevention (genetic counselling), diagnosis (genetic diagnosis of vulnerability), and treatment (pharmacogenomics) of these disorders.

The dialectics of heroin and methadone in Ireland

In this paper, I reflect on two of my intertwined research interests. The first is my professional engagement with researching drug use and abuse in Ireland, especially heroin addiction, in applied ethnographic projects, generally answering a specific set of questions on how services for 'drug addiction' work. My second interest is the historical construction of 'addiction' and the discursive intersections that produce various kinds of power, subjects, and techniques around this concept. I find the dialectical relationship between heroin and methadone in Ireland, especially the emergence of heroin 'injecting rooms', as a window into how drugs are social things. Drugs and the bodies who take them live in complex moral worlds, not as inert objects surrounded by abstract human creations. These worlds are an integral part of how 'addiction' works and how drugs treating addiction are actually used. Without a deeper understanding of such complexities we will continue to miss key issues in the lives of people we hope to help.

Prevalence and socio-demographic correlates of law enforcement involvement among treatment-seeking adult males with opioid use disorder

AIM

Use of various substances, including opioid use is often associated with coming in contact with the law- enforcement agencies. Data are scarce on the unique socio-demographic and clinical correlates from the Indian population. The current study aims to explore the clinical and socio-demographic correlations of law enforcement involvement among treatment-seeking adult males with opioid use disorder.

METHOD

We screened adult males presenting for the treatment of opioid use disorder at the outpatient department of a tertiary care hospital in North India. We measured law enforcement involvement by asking if the patient was ever apprehended by police, had any pending legal case against them, had any history of drug trafficking, or had any history of incarceration. We divided the entire study population based on law enforcement involvement versus no involvement. We compared both the groups in terms of socio-demographic and other clinical parameters. Binary logistic regression analysis was carried out to find the independent predictors of law enforcement involvement in this population.

RESULTS

Out of a total of 204 patients with opioid use disorder, sixty-two participants (30.4%) had a history of law enforcement involvement, with all 62 of them being apprehended by the police at least once, 27 (13.2%) had a history of incarceration, 13 (6.4%) had a criminal case pending and 3 (1.5%) had a history of peddling drugs. We found out that high-risk sexual behavior, injecting drug use, and urban residence were associated with involvement with law enforcement.

CONCLUSION

Getting involved with the law- enforcement agencies among patients with opioid use disorders may be associated with high-risk behaviors. Legal involvement among opioid-dependent individuals may also be an impediment to the treatment processes, especially when such patients are incarcerated.

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

Background

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

Methods

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

Results

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

Conclusion

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

Psychosocial resources and strains and health services use among adult illicit drug users from the Miami-Dade community

This study builds on previous research concerning the associations of positive and negative dimensions of the self-concept and social relationships, respectively, with medical treatment seeking actions by modeling potentially positive and negative effects simultaneously. Using data from the first wave of a large community study including adult (20-93) drug users (n = 318), multivariate linear regression analysis presents the effects of psychosocial resources on drug users' medical treatment seeking in six progressive models. Social resources such as family support, family conflict, and friend support account for variation in medical treatment seeking actions in adult drug users. Dimensions of the self-concept, including perception of powerlessness and self-esteem also influence medical treatment seeking actions in adult drug users. Moderation tests reveal that the presence of family problems related to drug use is associated with a lower likelihood of taking treatment-seeking action in the context of greater family support. This study assessed how positive and negative dimensions of social relationships and the self-concept can jointly influence medical treatment seeking actions. Implications for medical treatment seeking action research are discussed.

The role of physical and psychological health problems in the drug use treatment process

The role of physical and psychological health is examined as a predictor of client engagement in prison-based drug treatment. A treatment process model was expanded to include physical and mental health issues. The sample included 6009 offenders in prison-based drug treatment, comprised of 67% male, 26% African American, 51% white, and 22% Hispanic; average age was 34.6. Half reported "some physical health concerns" and mentioned a variety of ailments. A fifth reported moderate stress on the Kessler Psychological Distress Scale (K10) and 15% reported PTSD based on the PTSD Check List (PCL). Structural equation modeling was used to model treatment engagement in terms of demographics, physical health concerns, psychological distress, HIV risky behaviors, self-esteem, decision making, and treatment motivation. Two random samples were created, with one used for estimation and the other for cross-validation. The findings suggested physical health and HIV risky behaviors have effects on client engagement through psychological functioning, and that psychological functioning has direct effects on treatment engagement.

Development of a resource allocation formula for substance misuse treatment services

Background

Funding for substance misuse services comprises one-third of Public Health spend in England. The current allocation formula contains adjustments for actual activity, performance and need, proxied by the Standardized Mortality Ratio for under-75s (SMR < 75). Additional measures, such as deprivation, may better identify differential service need.

Methods

We developed an age-standardized and an age-stratified model (over-18s, under-18s), with the outcome of expected/actual cost at postal sector/Local Authority level. A third, person-based model incorporated predictors of costs at the individual level. Each model incorporated both needs and supply variables, with the relative effects of their inclusion assessed.

Results

Mean estimated annual cost (2013/14) per English Local Authority area was £5 032 802 (sd: 3 951 158). Costs for drug misuse treatment represented the majority (83%) of costs. Models achieved adjusted R-squared values of 0.522 (age-standardized), 0.533 (age-stratified over-18s), 0.232 (age-stratified under-18s) and 0.470 (person-based).

Conclusion

Improvements can be made to the existing resource allocation formulae to better reflect population need. The person-based model permits inclusion of a range of needs variables, in addition to strong predictors of cost based on the receipt of treatment in the previous year. Adoption of this revised person-based formula for substance misuse would shift resources towards more deprived areas.

Use of opioid substitution therapies in the treatment of opioid use disorder: results of a UK cost-effectiveness modelling study

AIMS

This study investigated the cost-effectiveness of buprenorphine maintenance treatment (BMT) and methadone maintenance treatment (MMT) vs no opioid substitution therapy (OST) for the treatment of opioid use disorder, from the UK National Health Service (NHS)/personal social services (PSS) and societal perspectives over 1 year.

METHODS

Cost-effectiveness of OST vs no OST was evaluated by first replicating and then expanding an existing UK health technology assessment model. The expanded model included the impact of OST on infection rates of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection.

RESULTS

Versus no OST, incremental cost-effectiveness ratios (ICERs) for BMT and MMT were £13,923 and £14,206 per quality-adjusted life year (QALY), respectively, from a NHS/PSS perspective. When total costs (NHS/PSS and societal) are considered, there are substantial savings associated with adopting OST; these savings are in excess of £14,032 for BMT vs no OST and £17,174 for MMT vs no OST over 1 year. This is primarily driven by a reduction in victim costs. OST treatment also impacted other aspects of criminality and healthcare resource use.

LIMITATIONS

The model's 1-year timeframe means long-term costs and benefits, and the influence of changes over time are not captured.

CONCLUSIONS

OST can be considered cost-effective vs no OST from the UK NHS/PSS perspective, with a cost per QALY well below the UK's willingness-to-pay threshold. There were only small differences between BMT and MMT. The availability of two or more cost-effective options is beneficial to retaining patients in OST programs. From a societal perspective, OST is estimated to save over £14,032 and £17,174 per year for BMT and MMT vs no OST, respectively, due to savings in victim costs. Further work is required to fully quantify the clinical and health economic impacts of different OST formulations and their societal impact over the long-term.

They Do Things Differently over There: Doctors, Drugs, and the “British System” of Treating Opiate Addiction

The “British System” for treating opiate problems developed in the early part of the 20th century. Marked by an absence of a centrally coordinated policy, the system allowed doctors freedom and flexibility in prescribing to patients with opiate-related problems. These core features of the system have been retained despite buffetings from heroin epidemics among the young in the 1960s and 1980s and the challenge of HIV/AIDS among injecting drug users. Crime reduction became the focus of British drug policy in the 1990s, but nevertheless, treatment is still recognized as a key component of integrated UK drug policy in the early 21st century. Independence and diversity have thrived over this time. So what does the British System comprise today? And where is it going for tomorrow?

Characteristics of individuals presenting to treatment for primary alcohol problems versus other drug problems in the Australian patient pathways study

BACKGROUND

People seeking treatment for substance use disorders often have additional health and social issues. Although individuals presenting with alcohol as the primary drug of concern (PDOC) account for nearly half of all treatment episodes to the Australian alcohol and other drug (AOD) service system, previous treatment cohort studies have focused only on the profile of Australian heroin or methamphetamine users. While studies overseas indicate that clients seeking treatment primarily for their drinking are less likely to experience social and economic marginalisation than those seeking treatment primarily for illicit or pharmaceutical drug use, very little research has directly compared individuals presenting with alcohol as the PDOC to those primarily presenting with other drugs as their PDOC.

METHODS

Seven hundred and ninety-six participants were recruited at entry to specialist AOD treatment in Victoria and Western Australia, and completed measures of demographic and social factors, substance use, quality of life, service use, and criminal justice involvement. We compared those with alcohol as their PDOC to those with other drugs as their PDOC using Pearson chi-square and Mann-Whitney U tests.

RESULTS

Rates of social disadvantage, poor quality of life, high severity of substance dependence, and past-year AOD, mental health, acute health, and social service use were high in all groups. However, participants with alcohol as the PDOC were older; more likely to have an educational qualification; less likely to report criminal justice involvement, housing/homelessness service use, tobacco smoking, or problems with multiple substances; and reported better environmental quality of life; but were more likely to have used ambulance services, than those with other drugs as their PDOC.

CONCLUSIONS

While those seeking treatment primarily for alcohol problems appear less likely to suffer some forms of social and economic disadvantage or to use multiple substances than those with a primary drug problem, they experience similarly high levels of substance dependence severity and mental health and AOD service use. These findings reinforce the need for AOD services to integrate or coordinate care with programs that address the many complexities clients frequently present with, while also acknowledging differences between those seeking treatment for alcohol versus other drug problems.

Low knowledge and perceived Hepatitis C risk despite high risk behaviour among injection drug users in Kathmandu, Nepal

BACKGROUND

In Nepal, prevalence of Hepatitis C (HCV) among injecting drug users (IDUs) has been measured at 50% and knowledge of the virus is low. Rehabilitation and harm reduction attendees constitute populations to whom health care providers can deliver services. As such, characterizing their drug use and risk profiles is important for developing targeted service delivery. We measured drug use and risk patterns of IDUs participating in residential rehabilitation as well as those contacted through needle exchanges to identify correlates of drug use frequency, risky injection practices as well as HCV testing, knowledge and perceived risk.

METHODS

We collected cross-sectional data from one-on-one structured interviews of IDUs contacted through needle-exchange outreach workers (n=202) and those attending rehabilitation centres (behaviour immediately prior to joining rehabilitation) (n=167).

RESULTS

Roughly half of participants reported injecting at least 30 times in the past 30 days and individuals with previous residential rehabilitation experience reported frequent injection far more than those without it. About one in fourteen respondents reported past week risky injection practices. Participants were over three times as likely to report risky injection if they consumed alcohol daily (17.2%) than if they did not (5.0%) (p=0.002). Those who reported injecting daily reported risky injection practices (11.9%) significantly more than non-daily injectors (1.8%) (p<0.001). Respondents reported high HCV infection rates, low perceived risk, testing history and knowledge. HCV knowledge was not associated with differences in risky injecting.

CONCLUSION

Treatment centres should highlight the link between heavy drinking, frequent injection and risky injecting practices. The link between rehabilitation attendance and frequent injection may suggest IDUs with more severe use patterns are more likely to attend rehabilitation. Rehabilitation centres and needle exchanges should provide testing and education for HCV. Education alone may not be sufficient to initiate change since knowledge did not predict lower risk.

Patient characteristics and predictors of completion in residential treatment for substance use disorders

Aims and method To identify the patient characteristics and rates of retention in a residential rehabilitation drug and alcohol service (Springhill) based on an eclectic model of care. Patients were assessed using the Alcohol and Drug Outcome Measure (ADOM), a brief tool designed for the New Zealand setting. We looked at correlations between demographic, social and drug use parameters. Logistic regression assessed the relative impact of each variable on completion. Results The 183 patients who completed the data collection did not differ from 47 non-completers by demographic data; 62.2% of patients completed the programme, with equal number of men and women. One in five participants was Maori, the indigenous minority. Alcohol (51.9%) was the commonest drug of misuse, with methamphetamine (16.4%) and cannabis (14.2%) also significant. Completers were more likely to be Maori, have conflict with family and housing problems, although the last became non-significant in logistic regression. Clinical implications Retention rates are higher in Springhill than in comparable programmes. Ethnicity and family conflict predict completion, although the reasons for this are unclear. ADOM is an effective tool that can be used in a clinical setting to enable analysis of service provision.

Estimation of life expectancy and the expected years of life lost among heroin users in the era of opioid substitution treatment (OST) in Taiwan

BACKGROUND

Opioid substitution treatment (OST) has been implemented in Taiwan since 2006. We estimated the life expectancy (LE) and expected years of life lost (EYLL) in a cohort of heroin users stratified by OST for comparison.

METHODS

A total of 1283 heroin users recruited from 2006 to 2008 were linked to the National Mortality Registry until the end of 2011. Among them, 983 received OST, while 300 did not. Kaplan-Meier estimation for survival was performed, and it was extrapolated to 50 years to obtain the LE using a semi-parametric method. We further estimated the EYLL for both cohorts by subtracting their life expectancies from the age- and sex-matched referents of the general population. Cause-specific standardized mortality ratios (SMRs) were calculated and compared with the national cohort to validate the representativeness of this sample.

RESULTS

After extrapolation to 50 years of survival, the estimated average LE and EYLL were 27.4 and 10.6 for OST subjects, respectively, while those of the non-OST were 20.2 and 18.4 years. The all-cause mortality rates (per 1000 person-years) in the observational period for the OST and non-OST group were 15.5 and 23.9, respectively, representing a 7.5- and 10.2-fold SMR compared to the general population, indicating a high representativeness for our sample. But SMR of suicide mortality elevated 16.2 and 3.1 folds in OST and non-OST group, respectively.

CONCLUSIONS

OST saves 7.8 EYLL more than non-OST after accounting for lead time bias. Effective suicide prevention programs could enhance its life-saving effect, especially among those co-morbid with depressive disorders.

The National Treatment Outcomes Research Study (NTORS) and its influence on addiction treatment policy in the United Kingdom

This paper describes the political origins of the National Treatment Outcomes Research Study (NTORS) and the outputs and impacts of the study. NTORS was designed to meet the request of the Health Secretary and of a Government Task Force for evidence about the effectiveness of the national addiction treatment services. NTORS was a prospective cohort study which investigated outcomes over a 5-year period of drug users admitted to four major treatment modalities: in-patient treatment, residential rehabilitation, methadone reduction and methadone maintenance programmes. The study investigated treatments delivered under day-to-day operating conditions. Outcomes showed substantial reductions in illicit drug use and reduced injecting risk behaviours. These changes were accompanied by improved psychological and physical health and by reductions in criminal behaviour. However, not all outcomes were so positive. There was a continuing mortality rate in the cohort of about 1% per year, and many clients continued to drink heavily throughout the 5-year follow-up. NTORS findings informed and influenced UK addiction treatment policy both at the time and subsequently. The findings were influential in supporting an immediate increase in funding for treatment, and Government Ministers have repeatedly cited NTORS as evidence of the effectiveness of addiction treatment. One finding that received political attention was that of the cost savings provided by treatment through reductions in crime. This important finding led to an unanticipated consequence of NTORS; namely, the greater focus on crime reduction that has increasingly been promoted as a political and social priority for drug misuse treatment.

Assessing traumatic experiences in screening for PTSD in substance use disorder patients: what is the gain in addition to PTSD symptoms?

Traumatic experiences have been linked with substance use disorders (SUD) and may be an important factor in the perpetuation of SUD, even in the absence of posttraumatic stress disorder (PTSD) symptoms. The purpose of the current study was to examine the relationship between childhood trauma and substance use severity in 192 SUD inpatients. Childhood trauma was assessed using the Traumatic Experiences Checklist (TEC). With variables derived from this measure in addition to PTSD symptoms, two regression models were created with alcohol use or drug use severity as dependent variables. Alcohol severity was explained by PTSD symptoms as well as the age of trauma. Drug severity was explained solely by PTSD symptoms. The clinical value of assessing childhood trauma in determining the addiction severity appears to be limited in comparison with PTSD symptoms.

Drug users' failure to modify alcohol consumption in response to hepatitis C

OBJECTIVE

To measure (a) the prevalence of problem drinking in a population of methadone-treated drug users, (b) independent associations with problem drinking, (c) the effect of hepatitis C status on drinking behaviour, (d) the knowledge of drug users of their hepatitis C status and their perception of their drinking behaviour and (e) the attitude of drug users to the effect of alcohol on hepatitis C virus (HCV) related disease.

METHOD

A cross sectional survey of 130 drug users in treatment at the National Drug Treatment Centre, Dublin was carried out. A questionnaire incorporated the Alcohol Use Disorders Identification Test (AUDIT), and data were collected on sociodemographics, drug use history, perceived HCV status and drinking behaviour, and attitudes to the impact of drinking on HCV related disease. Hepatitis serology and drug urine data were collected from clinical records.

RESULTS

The prevalence of problem drinking was 41% (95% CI 33-51%). Unstable accommodation, older age, male gender and longer duration of heroin use were independent associations with being a problem drinker. There was no significant difference in the prevalence of problem drinking across HCV status. Knowledge of HCV status was accurate, however 35% of those identified as AUDIT cases failed to recognise their problem drinking.

CONCLUSION

HCV infection among Irish drug users is compounded by a high prevalence of problem drinking with drug users failing to modify their drinking in response. Incorrect perception of problem drinking status could be a barrier to addressing this potentially remediable risk factor.

Mortality, causes of death and risk factors for death among primary amphetamine users in the Swedish criminal justice system

This study examined mortality and predictors of death in 1,396 primary amphetamine users (85% males) who were interviewed with the Addiction Severity Index in the Swedish criminal justice system during 2000-2006 and followed through 2008. Forty-nine clients deceased (standardized mortality ratio 4.1 [3.0-5.4]), at least 84% of deaths were violent or drug-related (12% suicides), and Cox regression analysis indicated that death was associated with frequent use of sedatives and less frequent use of amphetamine. No female deaths were observed; death and male gender were associated in binary analysis. Implications for diagnostics and treatment are discussed.

Making sense of differing overdose mortality: contributions to improved understanding of European patterns

The European Monitoring Centre for Drugs and Drug Addiction, EMCDDA, publishes statistics for overdose deaths giving a European mean number, and ranking nations in a national 'league table' for overdose deaths. The interpretation of differing national levels of mortality is more problematic and more complex than is usually recognised. Different systems are used to compile mortality data and this causes problems for cross-national comparisons. Addiction behaviour can only be properly understood within its specific social and environmental ecology. Risk factors for overdose, such as the type of drug consumed, and the route of administration, are known to differ across countries. This paper describes problems associated with ranking and suggests how mortality data might be used in high-level countries aiming at reduction in the number of overdose deaths.

Patterns, determinants and barriers of health and social service utilization among young urban crack users in Brazil

Background

Crack use is prevalent across the Americas, and specifically among marginalized urban street drug users in Brazil. Crack users commonly feature multiple physical and mental health problems, while low rates of and distinct barriers to help service use have been observed in these populations. This study examined profiles and determinants of social and health service utilization, and unmet service needs, in a two-city sample of young (18–24 years), marginalized crack users in Brazil.

Methods

N = 160 study participants were recruited by community-based methods from impoverished neighborhoods in the cities of Rio de Janeiro (n = 81) and Salvador (n = 79). A mixed methods protocol was used. Participants’ drug use, health, and social and health service utilization characteristics were assessed by an anonymous interviewer-administered questionnaire completed in a community setting; descriptive statistics on variables of interest were computed. Service needs and barriers were further assessed by way of several focus groups with the study population; narrative data were qualitatively analyzed. The study protocol was approved by institutional ethics review boards; data were collected between November 2010 and June 2011.

Results

The majority of the sample was male, without stable housing, and used other drugs (e.g., alcohol, marijuana). About half the sample reported physical and mental health problems, yet most had not received medical attention for these problems. Only small minorities had utilized locally available social or health services; utilization appeared to be influenced by sex, race and housing characteristics in both sites. Participants cited limited service resources, lack of needs-specific professional skills, bureaucratic barriers and stigma as obstacles to better service access. However, most respondents stated strong interest and need for general social, health and treatment services designed for the study population, for which various key features were emphasized as important.

Conclusions

The study contributes substantive evidence to current discussions about the development and utilization of health and treatment interventions for crack use in Brazil. Based on our data, crack users’ social, service needs are largely unmet; these gaps appear to partly root in systemic barriers of access to existing services, while improved targeted service offers for the target population seem to be needed also.

Suicide and other-cause mortality among heroin users in Taiwan: a prospective study

AIMS

The present study investigates one-year incidence of mortality from suicide and other causes among heroin users in Taiwan.

DESIGN

A prospective national register-based cohort study.

SETTING

All heroin users who attended the methadone maintenance treatment (MMT) programs in all treatment centers in Taiwan.

PARTICIPANTS

The sample comprised 10,842 heroin users attending MMT. Between Jan 2006 and Dec 2007, cases were identified through the multiple-center register system and followed until Dec 2008 for date and cause of death on the Taiwan national mortality database.

MEASUREMENTS

Standardized mortality ratios within one year of starting MMT were calculated as a ratio of actual versus expected numbers of deaths in the general population in Taiwan. Cox regression models were fitted to estimate the effects of gender, age, education and marital status as well as heroin related behaviors.

FINDINGS

In total, 256 cases died, 67 through suicide. The mortality rate (per 100 person-years) in the first year of all-cause and suicide was 1.71 and 0.45 respectively, representing 7.5- and 18.4-fold age- and gender-standardized mortality ratio (SMR) compared to the general population. Besides, the mortality rate in the first year of overdoses, murder, HIV, somatic was 0.19, 0.02, 0.07, and 0.75 respectively, representing 68.4-, 27.7-, 76.8-, and 4.3-fold SMR increases to the general population. Older age and unemployment were independent risk factors for mortality. Females had higher standardized mortality ratio than males for suicide and all-cause mortality.

CONCLUSIONS

Results showed higher risk of suicide and other-cause mortality among heroin users in MMT than general population. Suicide is an important contributor to overall excess mortality among heroin users in MMT, and especially among women. Suicide prevention and physical health monitoring are important components of MMT programs.

Work and the journey to recovery: exploring the implications of welfare reform for methadone maintenance clients

BACKGROUND

An emphasis on welfare reform has been a shared concern of recent UK governments, with the project of transforming the provision of welfare gathering pace over the past six years. Replicating active labour market policies pursued across the globe, successive governments have used welfare-to-work programmes as mechanisms to address worklessness. Since 2008, problem drug users (PDUs) have been added to a list of groups for whom intervention is deemed necessary to encourage, enable, and sometimes coerce them into paid employment. This approach is underpinned by three beliefs relating to paid work: it sustains recovery, has a transformative potential and should be the primary duty of the responsible citizen. Using policy developments in the UK as a case study, the article explores the implications for methadone maintenance clients of connecting drug policy (premised on the belief that work is central to recovery) with welfare policy (which at present is preoccupied with reducing worklessness).

METHODS

A critical analysis of policy documents, including drug strategies, Green and White papers and welfare reform legislation, alongside a review of relevant academic literature.

RESULTS

The 'work first' approach which underpins current labour market activation policies in the UK and elsewhere is insufficiently flexible to accommodate the diverse needs of PDUs in recovery, and is particularly particular problematic when combined with a 'social deficit' model which concentrates on individual rather than structural barriers to employability. The use of payment-by-results mechanisms to provide employment services, coupled with the use of sanctions for those who do not engage, is likely to be particularly problematic for methadone maintenance clients.

CONCLUSION

Welfare reform in the UK is likely to undermine the recovery of methadone maintenance clients. Further research is urgently needed to explore its impact on this sub-group of PDUs, alongside comparative studies to determine best practice in integrating drug and welfare policies.

Drug spend and acquisitive offending by substance misusers

AIM

The need to generate income to fund drug misuse is assumed to be a driver of involvement in acquisitive crime. We examined the influence of drug misuse expenditure, and other factors, on acquisitive offending.

METHODS

Clients (N=1380) seeking drug treatment within 94 of 149 Drug Action Teams (DATs) across England completed a comprehensive survey, incorporating validated scales and self-report measures, such as levels of drug and alcohol use and offending.

RESULTS

Forty per cent (N=554) had committed acquisitive crime in the previous month. Regression analysis showed that acquisitive offending was associated with the presence of problematic use of crack cocaine, poly-drug use, sharing injecting equipment, unsafe sex, overdose risk, higher drug spend, unemployment, reduced mental wellbeing, and younger age.

CONCLUSIONS

Rates of acquisitive crime among drug users are high. Drug using offenders can be distinguished from drug using non-offenders by problematic crack cocaine use, younger age, income-related factors, and indicators of a chaotic life style and complex needs. Behavioural and demographic factors were associated more strongly with acquisitive crime than drug use expenditure, suggesting that the need to finance drug use is not necessarily the main factor driving acquisitive offending by drug users.

BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP

The British Association for Psychopharmacology guidelines for the treatment of substance abuse, harmful use, addiction and comorbidity with psychiatric disorders primarily focus on their pharmacological management. They are based explicitly on the available evidence and presented as recommendations to aid clinical decision making for practitioners alongside a detailed review of the evidence. A consensus meeting, involving experts in the treatment of these disorders, reviewed key areas and considered the strength of the evidence and clinical implications. The guidelines were drawn up after feedback from participants. The guidelines primarily cover the pharmacological management of withdrawal, short- and long-term substitution, maintenance of abstinence and prevention of complications, where appropriate, for substance abuse or harmful use or addiction as well management in pregnancy, comorbidity with psychiatric disorders and in younger and older people.

Drug treatments in criminal justice settings

The available evidence suggests that drug treatment can lead to modest, but real, reductions in criminal offending for drug-using criminal offenders. Considering the scope of the problem of drug-related crime and the expense of dealing with these issues, even marginal improvements can lead to important aggregate savings in both economic and humanitarian terms. More randomized, controlled trials of drug treatment in criminal justice programs will lead to a more sophisticated understanding of what kind of treatment works best for this group.

Impact of an 18-month, NHS-based, treatment exposure for heroin dependence: results from the London Area Treat 2000 Study

We set out to examine the impact of treatment for heroin dependence on drug use, injecting behavior, health problems, criminality, and physical and mental health over 18 months among heroin-dependent Londoners. A total of 100 heroin users were recruited for this longitudinal prospective cohort study with repeated measures (T0 as baseline, T1 after 9 months, and T2 after 18 months). The psychiatric evaluation and assessment of drug abuse levels were determined by the CIDI and the EuropASI. Additional evaluations included the WHO-DAS II for disability assessment and the UCLA-SSI for social support. The number of days of heroin use in the 30 days previous to each single assessment significantly reduced over time (p < .001). Similar reduction levels were observed for cocaine (p < .05), benzodiazepines (p < .001), and polydrug abuse (p < .001), but not for cannabis and alcohol. The number of injecting occasions reduced in parallel, with increase in days in work and reduction of money spent for drug acquisition activities and money obtained from criminal/illegal activities. The number of subjects experiencing suicidal ideation reduced over time (p < .05). In line with previous suggestions, significant reductions in drug use, criminality, psychopathology, and injecting behavior following treatment exposure for heroin dependence were observed. It is, however, of concern that alcohol and cannabis misuse levels remained unchanged.

Associations between polysubstance use and psychiatric problems in a criminal justice population in Sweden

BACKGROUND

Polysubstance use is common in substance users, and may complicate their clinical course. This study, in a criminal justice setting in Sweden, examines the association between the number of concurrently used substance types and psychiatric symptoms during 30 days before incarceration, while controlling for background variables such as family history (drug and alcohol problems, psychiatric problems, criminality), demographic data and history of emotional, physical or sexual abuse.

METHODS

The data material comprised 5659 criminal justice clients reporting a substance use problem, examined with the Addiction Severity Index. Variables were compared in a multinomial regression analysis, comparing clients reporting one (n=1877), two (n=1408), three (n=956), four (n=443) and five or more (n=167) substance types.

RESULTS

The 30-day prevalence of most psychiatric symptoms included in the study (depression, anxiety, cognitive problems, hallucinations, difficulty controlling violent behaviour, suicidal ideation, suicide attempts) was higher in individuals with a higher number of concurrent substance types used. In multinomial regression analysis, while controlling for background variables, these associations remained for concurrent suicidal ideation, cognitive problems, hallucinations and violent behaviour, with the latter two being associated with the higher numbers of substance types. Binge alcohol drinking, tranquilizers, opioids and the number of substance types reported were associated with several of the psychiatric symptoms.

CONCLUSIONS

In the present criminal justice setting in Sweden, the use of multiple substance types and concurrent psychiatric symptoms appear to be associated, and a sub-group reporting particularly high numbers of concurrent substance types are particularly likely to report potentially severe psychiatric problems.

The discriminative stimulus effects of midazolam are resistant to modulation by morphine, amphetamine, dizocilpine, and γ-butyrolactone in rhesus monkeys

RATIONALE

Although abuse of benzodiazepines alone is uncommon, it is high in polydrug abusers, including those who primarily use opioids or stimulants.

OBJECTIVES

This study investigated whether drugs that are abused (e.g., amphetamine) or drugs that have mechanisms of action similar to abused drugs (e.g., morphine) alter the discriminative stimulus effects of the benzodiazepine midazolam.

METHODS

Three rhesus monkeys discriminated 0.56 mg/kg of midazolam while responding under a fixed-ratio 10 schedule of food presentation. Dose-effect curves were determined for midazolam alone and in the presence of morphine (opioid receptor agonist), amphetamine (dopamine receptor indirect agonist), dizocilpine (N-methyl-D: -aspartic acid receptor antagonist), or γ-butyrolactone (prodrug of γ-hydroxybutyrate, which acts primarily at GABA(B) receptors).

RESULTS

Doses of midazolam larger than 0.32 mg/kg produced ≥80% midazolam-lever responding. When administered alone, morphine, amphetamine, dizocilpine, and γ-butyrolactone did not produce midazolam-lever responding, although large doses of each drug eliminated responding; when administered in combination with midazolam, they did not alter the discriminative stimulus effects of midazolam up to doses that markedly decreased response rates.

CONCLUSIONS

The current study demonstrates a lack of modulation of the discriminative stimulus effects of midazolam by morphine, amphetamine, dizocilpine, and γ-butyrolactone. Other effects of benzodiazepines, such as their reinforcing effects, might be altered by these other drugs, or benzodiazepines might modulate the discriminative stimulus or reinforcing effects of the other drugs, which might contribute to the relatively high incidence of benzodiazepine abuse among polydrug abusers.

Sex differences amongst dependent heroin users: histories, clinical characteristics and predictors of other substance dependence

INTRODUCTION AND AIMS

To examine differences in the characteristics and histories of male and female dependent heroin users, and in the clinical characteristics associated with multiple substance dependence diagnoses.

DESIGN AND METHODS

1513 heroin dependent participants underwent an interview covering substance use and dependence, psychiatric history, child maltreatment, family background, adult violence and criminal history. Family background, demographic and clinical characteristics were analysed by sex. Ordinal regression was used to test for a relationship between number of substance dependence diagnoses and other clinical variables.

RESULTS

Women were more likely to experience most forms of child maltreatment, to first use heroin with a boyfriend or partner, to experience ongoing adult violence at the hands of a partner, and to have a poorer psychiatric history than men. Males had more prevalent lifetime substance dependence diagnoses and criminal histories and were more likely to meet the criteria for ASPD. Predictors of multiple substance dependence diagnoses for both sexes were mental health variables, antisocial behaviour, childhood sexual abuse, victim of adult violence, younger age at first cannabis use and overdose. As the number of dependence diagnoses increased, clinical and behavioural problems increased. Childhood emotional neglect was related to increasing dependence diagnoses for females but not males, whereas PTSD was a significant predictor for males but not females.

DISCUSSION AND CONCLUSIONS

Mental health problems, other substance dependence, childhood and adult trauma were common in this sample, with sex differences indicating different treatment needs and possible different pathways to heroin dependence for men and women.

Heroin use, dependence, and attitudes to treatment in non-treatment-seeking heroin users: a pilot study

Much research examining heroin users utilizes treatment samples; non-treatment-seeking heroin users are not well understood. It is unclear whether this group can avoid impaired control or negative sequelae commonly observed in treatment-seeking populations. During 2000 and 2001, we recruited 69 non-treatment-seeking heroin users with no treatment history. Heroin use, management strategies, treatment attitudes, and risk behaviors were assessed; the DSM-IV checklist and severity of dependence scale were completed. Study limitations and implications for heroin use and its treatment are discussed.

Problem drinking in relation to treatment outcome among opiate addicts in methadone maintenance treatment

This study analyzed indicators of alcohol-related problems in opiate addicts before, during, and after leaving methadone maintenance treatment (MMT), in relation to illicit drug use and retention in treatment. The study was based on 204 patients, admitted to MMT for the first time between 1 January 1995 and 31 July 2000, and followed until 31 December 2000. Three measures were used to indicate alcohol use and alcohol-related problems; records of hospital care with an alcohol-related diagnosis, any treatment with alcohol-sensitizing drugs (disulfiram or calcium carbimide) during MMT, and results of the 5-hydroxytryptophol to 5-hydroxyindoleacetic acid ratio (5HTOL/5HIAA) in urine, a sensitive biomarker for recent drinking. Use of illicit drugs was determined by routine urine drug testing. About one third of the patients (n = 69) had a lifetime prevalence of hospital treatment for an alcohol-related diagnosis, 45 of whom had been hospitalized (mean 4.2 stays) prior to the start of MMT. There was a significant association (p<0.05) between the number of alcohol-related diagnoses prior to treatment and a positive 5HTOL/5HIAA test during MMT. The alcohol indicators first became positive on average 1.6 years after admission to treatment, compared with after about 4 months for illicit drugs. Use of cannabis or benzodiazepines was significantly associated with alcohol use. Female methadone patients with indications of alcohol-related problems relapsed more often into illicit drug use than did women without such indications (3.9 vs. 2.5 relapse periods/year; p<0.005), whereas no significant association was found for men. The results of the present study indicate that drinking problems among patients undergoing MMT is associated with an increased risk of relapse into illicit drug use and with discharge from treatment. Concurrent treatment of alcohol-related problems, including systematic monitoring of alcohol use, therefore should be recommended to reduce the risk for relapse into illicit drug use and improve overall treatment outcome in MMT.

Health and well-being outcomes for drug-dependent offenders on the NSW Drug Court programme

Given the centrality of drug treatment to the drug court framework, the proliferation of drug courts in the United States, and their emergence more recently in Australia, it is surprising that such little attention has been given to assessing their therapeutic effect. This evaluation aimed to assess the health and well-being of drug-dependent offenders diverted to the New South Wales Drug Court, and monitor changes in their health and well-being throughout 12 months of programme participation. The study consisted of baseline interviews with 202 offenders accepted into the programme between February 1999 and April 2000, and follow-up interview at 4, 8 and 12 months with participants who remained on the programme. Health and well-being was assessed at each follow-up using the Short Form-36 Health Survey (SF-36) the OTI social functioning scale, and self-reported spending as a proxy for illicit drug use. The health of male Drug Court participants prior to commencing the programme was significantly poorer than Australian population norms. The results provided evidence of significant and sustained improvements in health and well-being for the 51 participants who competed each follow-up interview. Furthermore, significant improvements were found for offenders who remained on the programme for at least 4 months but less than 12 months. However, the positive health outcomes are limited by the low programme retention rate. These results indicate that significant health outcomes can be achieved for at least some heavily drug-dependent, recidivist offenders through the drug court model. [Freeman K. Health and well-being outcomes for drug-dependent offenders on the NSW Drug Court programme.

Non-injecting routes of administration among entrants to three treatment modalities for heroin dependence

A sample of 535 entrants to opioid dependence treatments across three treatment modalities were administered a structured interview to ascertain the prevalence of non-injecting heroin use. Ten per cent of participants had used heroin primarily by smoking/inhaling in the month preceding interview, and 9% had used heroin and other drugs exclusively by non-injecting routes. Non-injectors were younger (25.3 vs. 29.5 years), had higher levels of education (10.6 vs. 10.0 years), were more likely to be employed (33 vs. 18%) and had lower levels of recent crime (31 vs. 56%). They also had shorter heroin using careers (5.1 vs. 9.9 years), fewer symptoms of dependence (5.1 vs. 5.6), had been enrolled in fewer previous treatment episodes (3.3 vs. 11.5) and had less extensive lifetime (8.0 vs. 9.1 drug classes) and recent (3.6 vs. 4.9) polydrug use. Non-injectors were substantially less likely to report lifetime (13% vs. 58%) or recent (2% vs. 29%) heroin overdoses. There were no differences between the general physical and psychological health of the two groups. While non-injectors had a lower level of post-traumatic stress disorder (29% vs. 34%), there were no differences in levels of major depression, attempted suicide, antisocial personality disorder, or borderline personality disorder. A substantial minority of Australian treatment entrants are now using heroin exclusively by non-injecting routes. While this group is younger, and has substantially reduced risk of overdose and blood borne virus transmission, the physical and psychological health of non-injectors mirrors that of injectors.

The characteristics of heroin users entering treatment: findings from the Australian Treatment Outcome Study (ATOS)

The current study aimed to describe the characteristics (demographics, drug use, mental and physical health) of entrants to treatment for heroin dependence in three treatment modalities; and to compare these characteristics with heroin users not in or seeking treatment. Participants were 825 current heroin users recruited from Sydney, Adelaide and Melbourne: 277 entering methadone/buprenorphine maintenance treatment (MT), 288 entering detoxification (DTX), 180 entering drug-free residential rehabilitation (RR) and 80 not in treatment (NT). Treatment entrants were generally long-term heroin users with previous treatment experience. The majority of the sample (55%) were criminally active in the month preceding interview. Injection-related health problems (74%) and a history of heroin overdose (58%) were commonly reported. There were high degrees of psychiatric co-morbidity, with 49% reporting severe psychological distress, 28% having current major depression, 37% having attempted suicide and 42% having a lifetime history of post-traumatic stress disorder. Personality disorders were also prevalent, with 72% meeting criteria for antisocial personality disorder and 47% screening positive for borderline personality disorder. Striking similarities were noted between the non-treatment and treatment groups in length of heroin use career, drug use and treatment histories.

Changes and predictors of change in the physical health status of heroin users over 24 months

AIMS

(i) To describe the course of physical health among the ATOS cohort over 24 months; and (ii) to examine the effects of treatment, drug use patterns and social and psychological factors on health status over 24 months.

DESIGN

Longitudinal cohort.

SETTING

Sydney, Australia.

PARTICIPANTS

A total of 615 heroin users recruited for the Australian Treatment Outcome Study (ATOS).

FINDINGS

The general health of the cohort improved significantly over 24 months. Significant predictors of poor health over 24 months were: being older, being female, past month heroin, other opiate and tobacco use, past month unemployment and current major depression. Spending a greater proportion of time in residential rehabilitation (RR) was associated with better health over 24 months. No other treatment factors demonstrated a significant, independent relationship with health.

CONCLUSIONS

The physical health of dependent heroin users is affected by drug use and psychosocial problems. RR treatment appears to be particularly beneficial to the health of heroin users, suggesting the importance of a comprehensive approach to improving health among this group.

Drug use and perceived treatment need among newly sentenced prisoners in England and Wales

AIMS

To investigate pre-custody levels of drug use among newly sentenced prisoners and factors associated with perceived drug treatment need.

DESIGN, SETTING AND PARTICIPANTS

A sample of 1457 prisoners was recruited to a general purpose longitudinal survey of convicted prisoners starting a new sentence.

MEASUREMENTS

Data were collected by structured interviews on reception to prison. Measures were taken of illicit drug use, drug treatment history, current treatment needs, psychological health and a range of social problems.

FINDINGS

Life-time use of heroin, crack cocaine, cocaine powder, amphetamines or cannabis was reported by 79% of prisoners. Cannabis was the drug reported most commonly, but approximately a third had used heroin or crack cocaine during the year before custody. Nearly half of recent drug users reported wanting help or support with a drug problem during their sentence. Dependence on heroin and cocaine, previous drug treatment, employment, accommodation and psychological health problems were all associated positively with perceived treatment need.

CONCLUSIONS

The prevalence of pre-custody drug use among this sample of newly sentenced prisoners was high. Because treatment need was associated with a range of drug, health and social factors, assessment and referral to appropriate interventions should occur as soon as possible on reception. Treatment should be coordinated with other services and support.