1
|
Marel C, Mills K, Visontay R, Wilson J, Darke S, Ross J, Slade T, Haber PS, Haasnoot K, Keaveny M, Tremonti C, Teesson M. Australian treatment outcome study: protocol for the 18-20-year follow-up of a prospective longitudinal cohort examining the natural history of heroin dependence and associated mortality, psychiatric and physical health, and health service use. BMJ Open 2020; 10:e039226. [PMID: 32660955 PMCID: PMC7359069 DOI: 10.1136/bmjopen-2020-039226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Opioid dependence is a global health priority, currently making the biggest contribution to drug-related deaths. The chronic, long-term persistence of heroin dependence over the life course requires investigation in prospective longitudinal studies, to better understand patterns and predictors of remission and relapse, as well as the impact of changes in substance use on a range of physical and mental health outcomes. Such knowledge is critical in order to identify modifiable risk factors that can be targeted for intervention. Crucial unanswered questions include the following: What are the long-term rates of mortality? What are the long-term patterns and predictors of heroin use, remission, psychiatric health and health service use? What are the long-term physical health consequences of heroin use? METHODS AND ANALYSIS The 18-20-year follow-up of the Australian Treatment Outcome Study (ATOS) cohort will examine the natural history of heroin dependence of an existing cohort of 615 people with heroin dependence, who were recruited into the study in 2001-2002. Five waves of follow-up interviews have since been completed, at 3-month, 1-year, 2-year, 3-year and 10-11-year post-baseline. At the 18-20-year follow-up, the ATOS cohort is (on average) approaching their 50s and an average of 30 years have passed since they first used heroin. The 18-20-year follow-up will consist of: (1) a structured interview; (2) physical health assessment; and (3) data linkage. The results of this follow-up will improve our understanding and management of age-related disorders in this population, which if not addressed in the immediate future, has the capacity to overwhelm treatment centres and aged care facilities. ETHICS AND DISSEMINATION Ethical approval has been granted for the study (Sydney Local Health District Royal Prince Alfred Zone, Human Research Ethics Committee X18-0512 & HREC/18/RPAH/733). The results of the study will be disseminated through published manuscripts, bulletins and technical reports, as well as conference, seminars, webinar and workshop presentations.
Collapse
Affiliation(s)
- Christina Marel
- Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Sydney, New South Wales, Australia
| | - Katherine Mills
- Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Sydney, New South Wales, Australia
| | - Rachel Visontay
- Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Sydney, New South Wales, Australia
| | - Jack Wilson
- Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Sydney, New South Wales, Australia
| | - Shane Darke
- National Drug and Alcohol Research Centre, UNSW, Sydney, New South Wales, Australia
| | - Joanne Ross
- National Drug and Alcohol Research Centre, UNSW, Sydney, New South Wales, Australia
| | - Tim Slade
- Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Sydney, New South Wales, Australia
| | - Paul S Haber
- University of Sydney Addiction Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Drug Health Services, Sydney Local Health District, Camperdown, New South Wales, Australia
| | - Katherine Haasnoot
- Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Sydney, New South Wales, Australia
| | - Madeleine Keaveny
- Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Sydney, New South Wales, Australia
| | - Chris Tremonti
- Drug Health Services, Sydney Local Health District, Camperdown, New South Wales, Australia
| | - Maree Teesson
- Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
2
|
Laqueille X, Lucet C. [Clinical aspects and therapeutic positioning in addictology]. Soins Psychiatr 2020; 41:12-15. [PMID: 32718520 DOI: 10.1016/s0241-6972(20)30014-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The concept of addiction emerged subsequent to the moral approaches of the end ofthe 19th century as a pathological behaviour. The manuals which classify mental disorders, together with the notion of substance-related disorders, enable them to be approached with a medical vision. The subject of numerous, often heated or divisive debates, addictology requires a clinical approach. The treatment of addiction must involve professionals from the medical, nursing, psychological and social fields. This multi-disciplinarity encourages each player to consider their own nursing identity while taking into account that of each other.
Collapse
Affiliation(s)
- Xavier Laqueille
- GHU Psychiatrie et neurosciences, service d'addictologie, centre hospitalier Sainte-Anne, 1 rue Cabanis, 75014 Paris, France; Université de Paris, faculté de médecine Paris centre, 15 rue de l'École-de-Médecine, 75006 Paris, France.
| | - Chloé Lucet
- GHU Psychiatrie et neurosciences, service d'addictologie, centre hospitalier Sainte-Anne, 1 rue Cabanis, 75014 Paris, France; Université de Paris, faculté de médecine Paris centre, 15 rue de l'École-de-Médecine, 75006 Paris, France
| |
Collapse
|
3
|
Teesson M, Marel C, Darke S, Ross J, Slade T, Burns L, Lynskey M, Memedovic S, White J, Mills KL. Trajectories of heroin use: 10-11-year findings from the Australian Treatment Outcome Study. Addiction 2017; 112:1056-1068. [PMID: 28060437 DOI: 10.1111/add.13747] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/25/2016] [Accepted: 01/04/2017] [Indexed: 11/29/2022]
Abstract
AIMS To identify trajectories of heroin use in Australia, predictors of trajectory group membership and subsequent outcomes among people with heroin dependence over 10-11 years. DESIGN Longitudinal cohort study. SETTING Sydney, Australia. PARTICIPANTS A total of 615 participants were recruited between 2001 and 2002 as part of the Australian Treatment Outcome Study (66.2% male; mean age 29 years). The predominance of the cohort (87.0%) was recruited upon entry to treatment (maintenance therapies, detoxification and residential rehabilitation), and the remainder from non-treatment settings (e.g. needle and syringe programmes). This analysis focused upon 428 participants for whom data on heroin use were available over 10-11 years following study entry. MEASUREMENTS Structured interviews assessed demographics, treatment history, heroin and other drug use, overdose, criminal involvement, physical health and psychopathology. Group-based trajectory modelling was used to: (i) identify trajectory groups based on use of heroin in each year, (ii) examine predictors of group membership and (iii) examine associations between trajectory group membership and 10-11-year outcomes. FINDINGS Six trajectory groups were identified [Bayesian Information Criterion (BIC) = -1927.44 (n = 4708); -1901.07 (n = 428)]. One in five (22.1%) were classified as having 'no decrease' in heroin use, with the probability of using remaining high during the 10-11 years (> 0.98 probability of use in each year). One in six (16.1%) were classified as demonstrating a 'rapid decrease to maintained abstinence'. The probability of heroin use among this group declined steeply in the first 2-3 years and continued to be low (< 0.01). The remaining trajectories represented other fluctuating patterns of use. Few baseline variables were found to predict trajectory group membership, but group membership was predictive of demographic, substance use and physical and mental health outcomes at 10-11 years. CONCLUSIONS Long-term trajectories of heroin use in Australia appear to show considerable heterogeneity during a decade of follow-up, with few risk factors predicting group membership. Just more than a fifth continued to use at high levels, while fewer than a fifth become abstinent early on and remained abstinent. The remainder showed fluctuating patterns.
Collapse
Affiliation(s)
- Maree Teesson
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia.,National Health and Medical Research Council (NHMRC) Centre for Research Excellence in Mental Health and Substance Use, University of New South Wales, Australia
| | - Christina Marel
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia.,National Health and Medical Research Council (NHMRC) Centre for Research Excellence in Mental Health and Substance Use, University of New South Wales, Australia
| | - Shane Darke
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Joanne Ross
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia.,National Health and Medical Research Council (NHMRC) Centre for Research Excellence in Mental Health and Substance Use, University of New South Wales, Australia
| | - Tim Slade
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia.,National Health and Medical Research Council (NHMRC) Centre for Research Excellence in Mental Health and Substance Use, University of New South Wales, Australia
| | - Lucy Burns
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Michael Lynskey
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Sonja Memedovic
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia.,National Health and Medical Research Council (NHMRC) Centre for Research Excellence in Mental Health and Substance Use, University of New South Wales, Australia
| | - Joanne White
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia.,National Health and Medical Research Council (NHMRC) Centre for Research Excellence in Mental Health and Substance Use, University of New South Wales, Australia
| | - Katherine L Mills
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia.,National Health and Medical Research Council (NHMRC) Centre for Research Excellence in Mental Health and Substance Use, University of New South Wales, Australia
| |
Collapse
|
4
|
Fleury MJ, Djouini A, Huỳnh C, Tremblay J, Ferland F, Ménard JM, Belleville G. Remission from substance use disorders: A systematic review and meta-analysis. Drug Alcohol Depend 2016; 168:293-306. [PMID: 27614380 DOI: 10.1016/j.drugalcdep.2016.08.625] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 08/22/2016] [Accepted: 08/23/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This paper presents a systematic review and meta-analysis of available evidence on remission rates for substance use disorders (SUDs), providing weighted mean estimates of SUD remission rates. The review also explores study-level characteristics that may explain variations in remission rates across studies. METHODS A comprehensive search strategy identified studies published between 2000 and 2015 with follow-up periods of at least three years or reported lifetime remission outcomes for potential inclusion in the review. Remission was defined as not meeting diagnostic criteria for abuse or dependence for a minimum period of six months, as of final follow-up. A single-group summary meta-analysis was performed. Pooled estimated annual remission rates (PEARRs) were calculated. Meta-regression techniques and subgroup analyses were used to explore the association between study remission rates and key selected variables. RESULTS Of 8855 studies identified, 21 met the eligibility criteria. The results suggested that 35.0% to 54.4% of individuals with SUDs achieved remission, and this occurred after a mean follow-up period of 17 years. The PEARRs projected few cases of SUD remission, between 6.8% and 9.1% in any given year. Studies that reported higher remission rates had longer follow-up periods, and lower sample retention rates. CONCLUSIONS Results support the contention that SUDs are more likely to be "chronic" or long term disorders than acute disorders for a substantial number of individuals. However, more longitudinal research is required. Treatment geared to chronicity, such as assertive community treatment and intensive case management, needs to be more readily available for SUD populations.
Collapse
Affiliation(s)
- M-J Fleury
- Department of Psychiatry, McGill University, Montreal, Canada.
| | - Akram Djouini
- Centre de recherche et d'expertise en dépendance du Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Centre-Sud-de-l'Île-de-Montréal (Addiction Rehabilitation Center-University Institute), Montreal, Canada.
| | - Christophe Huỳnh
- Centre de recherche et d'expertise en dépendance du Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Centre-Sud-de-l'Île-de-Montréal (Addiction Rehabilitation Center-University Institute), Montreal, Canada.
| | - Joël Tremblay
- Department of Psycho-education, Université du Québec à Trois-Rivières, Trois-Rivières, Canada.
| | - Francine Ferland
- Centre de réadaptation en dépendance du CIUSSS de la Capitale-Nationale (Addiction Rehabilitation Center), Université Laval, Québec, Canada.
| | - J-M Ménard
- CIUSSS de-la-Mauricie-et-du-Centre-du-Québec (Addiction Rehabilitation Center), Trois-Rivières, Canada.
| | | |
Collapse
|
5
|
Amundsen EJ, Bretteville-Jensen AL, Kraus L. Estimating incidence of problem drug use using the Horwitz-Thompson estimator - A new approach applied to people who inject drugs in Oslo 1985-2008. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2016; 27:36-42. [PMID: 26718208 DOI: 10.1016/j.drugpo.2015.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 08/12/2015] [Accepted: 11/04/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND The trend in the number of new problem drug users per year (incidence) is the most important measure for studying the diffusion of problem drug use. Due to sparse data sources and complicated statistical models, estimation of incidence of problem drug use is challenging. The aim of this study is to widen the palette of available methods and data types for estimating incidence of problem drug use over time, and for identifying the trends. METHODS This study presents a new method of incidence estimation, applied to people who inject drugs (PWID) in Oslo. The method took into account the transition between different phases of drug use progression - active use, temporary cessation, and permanent cessation. The Horwitz-Thompson estimator was applied. Data included 16 cross-sectional samples of problem drug users who reported their onset of injecting drug use. We explored variation in results for selected probable scenarios of parameter variation for disease progression, as well as the stability of the results based on fewer years of cross-sectional samples. RESULTS The method yielded incidence estimates of problem drug use, over time. When applied to people in Oslo who inject drugs, we found a significant reduction of incidence of 63% from 1985 to 2008. This downward trend was also present when the estimates were based on fewer surveys (five) and in the results of sensitivity analysis for likely scenarios of disease progression. CONCLUSION This new method, which incorporates temporarily inactive problem drug users, may become a useful tool for estimating the incidence of problem drug use over time. The method may be less data intensive than other methods based on first entry to treatment and may be generalized to other groups of substance users. Further studies on drug use progression would improve the validity of the results.
Collapse
Affiliation(s)
- Ellen J Amundsen
- Norwegian Institute for Alcohol and Drug Research, P.O. Box 565 Sentrum, No-0105 Oslo, Norway.
| | | | - Ludwig Kraus
- IFT, Institut für Therapiforschung, Parzivalstraße 25, 80804 Munich, Germany; Centre for Social Research on Alcohol and Drugs, SoRAD, Stockholm University, Stockholm, Sweden
| |
Collapse
|
6
|
Sordo L, Bravo MJ, Barrio G, Indave BI, Degenhardt L, Pastor-Barriuso R. Potential bias due to outcome-related loss to follow-up in cohort studies on incidence of drug injection: systematic review and meta-analysis. Addiction 2015; 110:1247-57. [PMID: 25845977 DOI: 10.1111/add.12940] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 10/10/2014] [Accepted: 03/30/2015] [Indexed: 02/05/2023]
Abstract
AIMS A systematic review and meta-analysis were conducted to synthesize results from cohort studies on initiation into drug injection among vulnerable populations, to quantify heterogeneity in the estimated incidence rates of drug injection and to identify potential sources of heterogeneity and bias. METHODS MEDLINE, EMBASE, PsycINFO and LILACS were searched for relevant studies published between 1980 and 2012. Investigators independently reviewed studies for inclusion, retrieved information on baseline population characteristics and follow-up features and assessed study quality. Study-specific incidence rates of drug injection were calculated as the number of new injectors divided by the person-years at risk. The I(2) statistic was used to quantify heterogeneity in incidence rates across studies, and random-effects meta-regression models were used to identify determinants of heterogeneity and bias. RESULTS Nine cohorts totalling 1843 participants met the inclusion criteria, with individual sample sizes of 70-415 participants and follow-up lengths of 6 months-3.4 years. The incidence of drug injection varied widely, from 2.1 to 24.2 cases per 100 person-years. The strong between-study heterogeneity (I(2) = 90%, P<0.001) was reduced significantly after accounting for the different follow-up lengths (I(2) = 17%, P = 0.30), with a 57% (95% confidence interval 46-66%) decrease in the pooled incidence of drug injection per 1-year increase in average follow-up. CONCLUSIONS The incidence of drug injection decreases sharply with increasing follow-up length in cohort studies on drug injection initiation. Low retention rates and potential for downward selection bias in cohort studies on drug injection initiation are caused primarily by greater loss to follow-up among individuals at higher risk of starting injection, compared with other participants.
Collapse
Affiliation(s)
- Luis Sordo
- National Center for Epidemiology, Carlos III Institute of Health, Madrid, Spain.,Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain.,Department of Preventive Medicine and Public Health, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Maria J Bravo
- National Center for Epidemiology, Carlos III Institute of Health, Madrid, Spain.,Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Gregorio Barrio
- National School of Public Health, Carlos III Institute of Health, Madrid, Spain
| | - B Iciar Indave
- Service of Preventive Medicine, Mostoles Hospital, Madrid, Spain
| | - Louisa Degenhardt
- National Drug and Alcohol Research Center, University of New South Wales, Sidney, Australia.,Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Roberto Pastor-Barriuso
- National Center for Epidemiology, Carlos III Institute of Health, Madrid, Spain.,Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
| |
Collapse
|
7
|
Xia Y, Seaman S, Hickman M, Macleod J, Robertson R, Copeland L, McKenzie J, De Angelis D. Factors affecting repeated cessations of injecting drug use and relapses during the entire injecting career among the Edinburgh Addiction Cohort. Drug Alcohol Depend 2015; 151:76-83. [PMID: 25869544 PMCID: PMC4464608 DOI: 10.1016/j.drugalcdep.2015.03.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Revised: 02/28/2015] [Accepted: 03/01/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND AIMS Injecting drug use is a chronic condition, with people who inject drugs (PWID) typically experiencing repeated cessations and relapses during their injection careers. We characterize patterns of ceasing and relapsing and the impact of opiate substitution treatment (OST) during the entire injecting careers of PWID in the Edinburgh Addiction Cohort (EAC). METHODS During 2005-2007, 432 surviving participants of the EAC were interviewed about their injecting histories. Adjusted associations between covariates and hazards of cessation and relapse were estimated using random-effects models. RESULTS OST was strongly associated with a higher hazard of cessation (HR = 1 .71, P < 0.001), but there was no significant evidence of association with hazard of relapse (HR = 0.81, P = 0.14). Women and older PWID were less likely to relapse (HR = 0.73, P = 0.02 and HR = 0.55, P < 0.001, respectively). Hazards of both cessation and relapse decreased monotonically with time since last relapse/cessation (both P < 0.001). An individual's hazard of cessation increased with his/her number of previous cessations (HR = 3.58 for 10+ previous cessations, P < 0.001), but there was no evidence that an individual's hazard of relapse changed with number of previous relapses (P = 0.37). There was heterogeneity in the individual hazards of both cessation and relapse. CONCLUSIONS OST was associated with reduced time to cessation, and there was some suggestion of increased time to relapse too. The likelihood of prolonged cessation is greater for women, increases with age, and decreases with time since last relapse.
Collapse
Affiliation(s)
- Yang Xia
- MRC Biostatistics Unit, Cambridge Institute of Public Health, Forvie Site, Robinson Way, Cambridge Biomedical Campus, Cambridge CB2 0SR, UK
| | - Shaun Seaman
- MRC Biostatistics Unit, Cambridge Institute of Public Health, Forvie Site, Robinson Way, Cambridge Biomedical Campus, Cambridge CB2 0SR, UK
| | - Matthew Hickman
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - John Macleod
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Roy Robertson
- Centre for Population Health Sciences, The University of Edinburgh, Medical Quad, Teviot Place, Edinburgh EH8 9AG, UK; Muirhouse Medical Group, 1 Muirhouse Avenue, Muirhouse, Edinburgh EH4 4PL, UK
| | - Lorraine Copeland
- Muirhouse Medical Group, 1 Muirhouse Avenue, Muirhouse, Edinburgh EH4 4PL, UK
| | - Jim McKenzie
- Muirhouse Medical Group, 1 Muirhouse Avenue, Muirhouse, Edinburgh EH4 4PL, UK
| | - Daniela De Angelis
- MRC Biostatistics Unit, Cambridge Institute of Public Health, Forvie Site, Robinson Way, Cambridge Biomedical Campus, Cambridge CB2 0SR, UK; Public Health England, Statistics, Modelling and Economics Department, Centre for Infectious Disease Surveillance and Control, 61 Colindale Avenue, London NW9 5EQ, UK
| |
Collapse
|
8
|
Abstract
Opioid addiction is associated with excess mortality, morbidities, and other adverse conditions. Guided by a life-course framework, we review the literature on the long-term course of opioid addiction in terms of use trajectories, transitions, and turning points, as well as other factors that facilitate recovery from addiction. Most long-term follow-up studies are based on heroin addicts recruited from treatment settings (mostly methadone maintenance treatment), many of whom are referred by the criminal justice system. Cumulative evidence indicates that opioid addiction is a chronic disorder with frequent relapses. Longer treatment retention is associated with a greater likelihood of abstinence, whereas incarceration is negatively related to subsequent abstinence. Over the long term, the mortality rate of opioid addicts (overdose being the most common cause) is about 6 to 20 times greater than that of the general population; among those who remain alive, the prevalence of stable abstinence from opioid use is low (less than 30% after 10-30 years of observation), and many continue to use alcohol and other drugs after ceasing to use opioids. Histories of sexual or physical abuse and comorbid mental disorders are associated with the persistence of opioid use, whereas family and social support, as well as employment, facilitates recovery. Maintaining opioid abstinence for at least five years substantially increases the likelihood of future stable abstinence. Recent advances in pharmacological treatment options (buprenorphine and naltrexone) include depot formulations offering longer duration of medication; their impact on the long-term course of opioid addiction remains to be assessed.
Collapse
|
9
|
Affiliation(s)
- Gene M. Heyman
- Department of Psychology, Boston College, Chestnut Hill, Massachusetts 02467; ,
| |
Collapse
|
10
|
Backmund M, Meyer K, Schütz C, Reimer J. Factors associated with suicide attempts among injection drug users. Subst Use Misuse 2011; 46:1553-9. [PMID: 21463204 DOI: 10.3109/10826084.2011.564443] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Injection drug users (IDUs) entering an urban low-threshold opiate detoxification unit in Munich, Germany, between 1991 and 1997 were asked for lifetime suicide attempts and administered a questionnaire, including sociodemographic, IDU-related, and drug user treatment related variables. Among 1,049 participants, 20% had ever tried to commit suicide. In the logistic regression, female gender, older age, drug user treatment experience, lack of drug user counseling, and emergency treatment were associated with attempted suicide. Regular screening for suicidal behavior in IDUs should be undertaken with a special focus to mention risk factors. The study's limitations are noted. This study was partially sponsored by the German Ministry of Health.
Collapse
Affiliation(s)
- Markus Backmund
- 1Department of Addiction Medicine, General Hospital Munich Schwabing, Munich, Germany
| | | | | | | |
Collapse
|
11
|
Fareed A, Casarella J, Amar R, Vayalapalli S, Drexler K. Methadone maintenance dosing guideline for opioid dependence, a literature review. J Addict Dis 2010; 29:1-14. [PMID: 20390694 DOI: 10.1080/10550880903436010] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
To date, methadone dosing is still an issue of debate and controversy among clinicians who are involved in methadone maintenance programs. The authors conducted a literature review to update clinicians about this issue and provide recommendations for proper methadone dosing. Studies eligible for inclusion in the review were retrieved from the PubMed database by searching for reports published between 1990 and September 2008 using the major medical subject headings Methadone (all fields) and dose. Only articles written in English were included. Additional reports were identified from the reference lists of retrieved articles and by manual review of the tables of contents of journals on drug of abuse included in the psychiatry and substance abuse subject category listing 2008 of the Journal Citation Reports. Abstracts of medical meetings were excluded. Twenty-four articles were included in the review. Twelve are randomized, controlled, or double-blind clinical trials, 10 are non-randomized and observational studies, and 2 are meta-analyses. Currently, the consensus is to have a goal for methadone dosing in the range of 60 to 100 mg daily. For patients who continue to use illicit opiates while prescribed this dose range, clinicians may consider doses greater than 100 mg daily. However, this is not the current consensus but rather is based on the limited promising data the authors have; it could be considered if the benefits outweigh the risks for some patients.
Collapse
Affiliation(s)
- Ayman Fareed
- Department of Psychiatry, Emory University, School of Medicine, Decatur, GA 30033, USA.
| | | | | | | | | |
Collapse
|
12
|
Abstract
ISSUES The toxicology of homicide offenders and victims, and homicide as a cause of death among psychoactive substance users. APPROACH Review of the toxicology of homicide, and homicide as a cause of death among psychoactive substance users. KEY FINDINGS A half or more of offenders are intoxicated by a psychoactive substance at the time of the homicide, with alcohol the most commonly reported substance. Levels of substances among victims are comparable with those seen among perpetrators. Among both offenders and victims, levels of substances far exceed population use. Among substance users, homicide specific mortality rates of substance users far exceed population rates. Reducing rates of alcohol and other drug consumption, at national and individual levels, can be expected to substantially reduce rates of, and risk for, homicide. CONCLUSIONS AND IMPLICATIONS Psychoactive substances are strongly associated with homicide. One of the major societal benefits that can be derived from active attempts to reduce alcohol and other drug use are reductions in homicide rates.
Collapse
Affiliation(s)
- Shane Darke
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia.
| |
Collapse
|
13
|
Calabria B, Degenhardt L, Briegleb C, Vos T, Hall W, Lynskey M, Callaghan B, Rana U, McLaren J. Systematic review of prospective studies investigating "remission" from amphetamine, cannabis, cocaine or opioid dependence. Addict Behav 2010; 35:741-9. [PMID: 20444552 DOI: 10.1016/j.addbeh.2010.03.019] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2009] [Revised: 03/09/2010] [Accepted: 03/31/2010] [Indexed: 11/16/2022]
Abstract
AIMS To review and summarize existing prospective studies reporting on remission from dependence upon amphetamines, cannabis, cocaine or opioids. METHODS Systematic searches of the peer-reviewed literature were conducted to identify prospective studies reporting on remission from amphetamines, cannabis, cocaine or opioid dependence. Searches were limited to publication between 1990 and 2009. Reference lists of review articles and important studies were searched to identify additional studies. Remission was defined as no longer meeting diagnostic criteria for drug dependence or abstinence from drug use; follow-up periods of at least three years were investigated. The remission rate was estimated for each drug type, allowing pooling across studies with varying follow-up times. RESULTS There were few studies examining the course of psychostimulant dependence that met inclusion criteria (one for amphetamines and four for cocaine). There were ten studies of opioid and three for cannabis dependence. Definitions of remission varied and most did not clearly assess remission from dependence. Amphetamine dependence had the highest remission rate (0.4477; 95%CI 0.3991, 0.4945), followed by opioid (0.2235; 95%CI 0.2091, 0.2408) and cocaine dependence (0.1366; 95%CI 0.1244, 0.1498). Conservative estimates of remission rates followed the same pattern with cannabis dependence (0.1734; 95%CI 0.1430, 0.2078) followed by amphetamine (0.1637; 95%CI 0.1475, 0.1797), opioid (0.0917; 95%CI 0.0842, 0.0979) and cocaine dependence (0.0532; 95%CI 0.0502, 0.0597). CONCLUSIONS The limited prospective evidence suggests that "remission" from dependence may occur relatively frequently but rates may differ across drugs. There is very little research on remission from drug dependence; definitions used are often imprecise and inconsistent across studies and there remains considerable uncertainty about the longitudinal course of dependence upon these most commonly used illicit drugs.
Collapse
Affiliation(s)
- Bianca Calabria
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW 2052, Australia.
| | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Kimber J, Copeland L, Hickman M, Macleod J, McKenzie J, De Angelis D, Robertson JR. Survival and cessation in injecting drug users: prospective observational study of outcomes and effect of opiate substitution treatment. BMJ 2010; 341:c3172. [PMID: 20595255 PMCID: PMC2895695 DOI: 10.1136/bmj.c3172] [Citation(s) in RCA: 148] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To examine survival and long term cessation of injecting in a cohort of drug users and to assess the influence of opiate substitution treatment on these outcomes. DESIGN Prospective open cohort study. SETTING A single primary care facility in Edinburgh. PARTICIPANTS 794 patients with a history of injecting drug use presenting between 1980 and 2007; 655 (82%) were followed up by interview or linkage to primary care records and mortality register, or both, and contributed 10,390 person years at risk; 557 (85%) had received opiate substitution treatment. MAIN OUTCOME MEASURES Duration of injecting: years from first injection to long term cessation, defined as last injection before period of five years of non-injecting; mortality before cessation; overall survival. RESULTS In the entire cohort 277 participants achieved long term cessation of injecting, and 228 died. Half of the survivors had poor health related quality of life. Median duration from first injection to death was 24 years for participants with HIV and 41 years for those without HIV. For each additional year of opiate substitution treatment the hazard of death before long term cessation fell 13% (95% confidence interval 17% to 9%) after adjustment for HIV, sex, calendar period, age at first injection, and history of prison and overdose. Conversely exposure to opiate substitution treatment was inversely related to the chances of achieving long term cessation. CONCLUSIONS Opiate substitution treatment in injecting drug users in primary care reduces this risk of mortality, with survival benefits increasing with cumulative exposure to treatment. Treatment does not reduce the overall duration of injecting.
Collapse
Affiliation(s)
- Jo Kimber
- Department of Social Medicine, University of Bristol, Bristol BS8 2PS
| | | | | | | | | | | | | |
Collapse
|
15
|
DeFulio A, Donlin WD, Wong CJ, Silverman K. Employment-based abstinence reinforcement as a maintenance intervention for the treatment of cocaine dependence: a randomized controlled trial. Addiction 2009; 104:1530-8. [PMID: 19686522 PMCID: PMC2729763 DOI: 10.1111/j.1360-0443.2009.02657.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
CONTEXT Due to the chronic nature of cocaine dependence, long-term maintenance treatments may be required to sustain abstinence. Abstinence reinforcement is among the most effective means of initiating cocaine abstinence. Practical and effective means of maintaining abstinence reinforcement programs over time are needed. OBJECTIVE To determine whether employment-based abstinence reinforcement can be an effective long-term maintenance intervention for cocaine dependence. DESIGN Participants (n = 128) were enrolled in a 6-month job skills training and abstinence initiation program. Participants who initiated abstinence, attended regularly and developed needed job skills during the first 6 months were hired as operators in a data entry business and assigned randomly to an employment-only (control, n = 24) or abstinence-contingent employment (n = 27) group. SETTING A non-profit data entry business. Participants Unemployed welfare recipients who used cocaine persistently while enrolled in methadone treatment in Baltimore. INTERVENTION Abstinence-contingent employment participants received 1 year of employment-based contingency management, in which access to employment was contingent upon provision of drug-free urine samples under routine and then random drug testing. If a participant provided drug-positive urine or failed to provide a mandatory sample, then that participant received a temporary reduction in pay and could not work until urinalysis confirmed recent abstinence. MAIN OUTCOME MEASURE Cocaine-negative urine samples at monthly assessments across 1 year of employment. RESULTS During the 1 year of employment, abstinence-contingent employment participants provided significantly more cocaine-negative urine samples than employment-only participants [79.3% and 50.7%, respectively; P = 0.004, odds ratio (OR) = 3.73, 95% confidence interval (CI) = 1.60-8.69]. Conclusions Employment-based abstinence reinforcement that includes random drug testing is effective as a long-term maintenance intervention, and is among the most promising treatments for drug dependence. Work-places could serve as therapeutic agents in the treatment of drug dependence by arranging long-term employment-based contingency management programs.
Collapse
Affiliation(s)
- Anthony DeFulio
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | | | | | | |
Collapse
|
16
|
Benefits of retention in methadone maintenance and chronic medical conditions as risk factors for premature death among older heroin addicts. J Psychiatr Pract 2009; 15:227-34. [PMID: 19461397 DOI: 10.1097/01.pra.0000351884.83377.e2] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Methadone maintenance treatment reduces rates of premature mortality in heroin addicts. However, few published studies have addressed the effectiveness of treatment, mortality rates, or causes of death in older (geriatric) patients maintained on methadone. Identifying risk factors for premature mortality and potential targets for early intervention may reduce rates of premature mortality in older patients maintained on methadone. METHODS We conducted a retrospective chart review for patients enrolled in the methadone maintenance program at the Atlanta Veterans Affairs Medical Center. We reviewed the charts of 91 patients and collected the following information: demographics (age, gender, marital status, and race); composite score at admission on the Addiction Severity Index (ASI); most recent ASI score for alcohol use, drug use, and medical, psychiatric, family, legal, and employment problems; results of urine drug screens for opiates, cocaine, and benzodiazepines (first 4 screens after admission and last 4 screens); dose and duration of methadone treatment; HIV and hepatitis B and C status; tobacco smoking; presence of diabetes mellitus, hypertension, heart disease, chronic obstructive pulmonary disease, or cancer; history of intravenous drug use; and missed primary care appointments (last five appointments). RESULTS A statistically significant association was found between diabetes mellitus and between liver and gastrointestinal cancer and premature mortality in this sample of older patients maintained on methadone (OR=30.79, p=0.008 for diabetes mellitus; OR=19.91, p=0.017 for cancer). Patients who remained in treatment showed statistically significant improvement in ASI scores for problems related to drug use and for psychiatric, medical, and legal problems. They showed a nonsignificant trend toward reduction of problems associated with alcohol use. The group of patients who dropped out of methadone treatment did not show statistically significant improvement on any area of the ASI except family problems. The group who remained in treatment also showed a statistically significant reduction in drug use when results of the first four and last four urine drug screens for opiates, cocaine, and benzodiazepines were compared (p<0.0001 for opiates and cocaine, p=0.02 for benzodiazepines).On the other hand, the group who dropped out of methadone treatment did not show any statistically significant reduction in drug use based on urine screens (p=0.05 for opiates, p=0.38 for cocaine, and p=0.53 for benzodiazepines). CONCLUSIONS The results presented here suggest potential targets for intervention related to lifestyle risk factors and comorbid medical conditions, such as nicotine dependence and diabetes mellitus, that may have the potential to improve health outcomes for older patients with opioid dependence.
Collapse
|
17
|
Crome I, Sidhu H, Crome P. No longer only a young man's disease--illicit drugs and older people. J Nutr Health Aging 2009; 13:141-3. [PMID: 19214343 DOI: 10.1007/s12603-009-0021-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
18
|
Bjornaas MA, Bekken AS, Ojlert A, Haldorsen T, Jacobsen D, Rostrup M, Ekeberg O. A 20-year prospective study of mortality and causes of death among hospitalized opioid addicts in Oslo. BMC Psychiatry 2008; 8:8. [PMID: 18271956 PMCID: PMC2277385 DOI: 10.1186/1471-244x-8-8] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2007] [Accepted: 02/13/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To study mortality rate and causes of death among all hospitalized opioid addicts treated for self-poisoning or admitted for voluntary detoxification in Oslo between 1980 and 1981, and to compare their mortality to that of the general population. METHODS A prospective cohort study was conducted on 185 opioid addicts from all medical departments in Oslo who were treated for either self-poisoning (n = 93, 1980), voluntary detoxification (n = 75, 1980/1981) or both (n = 17). Their median age was 24 years; with a range from 16 to 41, and 53% were males. All deaths that had occurred by the end of 2000 were identified from the Central Population Register. Causes of death were obtained from Statistics Norway. Standardized mortality ratios (SMRs) were computed for mortality, in general, and in particular, for different causes of death. RESULTS During a period of 20 years, 70 opioid addicts died (37.8%), with a standardized mortality ratio (SMR) equal to 23.6 (95% CI, 18.7-29.9). The SMR remained high during the whole period, ranging from 32.4 in the first five-year period, to 13.4 in the last five-year period. There were no significant differences in SMR between self-poisonings and those admitted for voluntarily detoxification. The registered causes of death were accidents (11.4%), suicide (7.1%), cancer (4.3%), cardiovascular disease (2.9%), other violent deaths (2.9%), other diseases (71.4%). Among the 50 deaths classified as other diseases, the category "drug dependence" was listed in the vast majority of cases (37 deaths, 52.9% of the total). SMRs increased significantly for all causes of death, with the other diseases group having the highest SMR; 65.8 (95% CI, 49.9-86.9). The SMR was 5.4 (95% CI, 1.3-21.5) for cardiovascular diseases, and 4.3 (95% CI, 1.4-13.5) for cancer. The SMR was 13.2 (95% CI, 6.6-26.4) for accidents, 10.7 (95% CI, 4.5-25.8) for suicides, and 28.6 (95% CI, 7.1-114.4) for other violent deaths. CONCLUSION The risk of death among opioid addicts was significantly higher for all causes of death compared with the general population, implying a poor prognosis over a 20-year period for this young patient group.
Collapse
Affiliation(s)
- Mari A Bjornaas
- Department of Acute Medicine, Ullevaal University Hospital, N-0407 Oslo, Norway.
| | - Anette S Bekken
- Department of Behavioural Sciences in Medicine, Institute of Basic Medical Sciences, University of Oslo, N-0317 Oslo, Norway
| | - Aasa Ojlert
- Department of Behavioural Sciences in Medicine, Institute of Basic Medical Sciences, University of Oslo, N-0317 Oslo, Norway
| | - Tor Haldorsen
- Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, N-0317 Oslo, Norway
| | - Dag Jacobsen
- Department of Acute Medicine, Ullevaal University Hospital, N-0407 Oslo, Norway
| | - Morten Rostrup
- Department of Acute Medicine, Ullevaal University Hospital, N-0407 Oslo, Norway
| | - Oivind Ekeberg
- Department of Acute Medicine, Ullevaal University Hospital, N-0407 Oslo, Norway,Department of Behavioural Sciences in Medicine, Institute of Basic Medical Sciences, University of Oslo, N-0317 Oslo, Norway
| |
Collapse
|
19
|
Haasen C, Verthein U, Degkwitz P, Berger J, Krausz M, Naber D. Heroin-assisted treatment for opioid dependence: randomised controlled trial. Br J Psychiatry 2007; 191:55-62. [PMID: 17602126 DOI: 10.1192/bjp.bp.106.026112] [Citation(s) in RCA: 149] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Heroin-assisted treatment has been found to be effective for people with severe opioid dependence who are not interested in or do poorly on methadone maintenance. AIMS To study heroin-assisted treatment in people on methadone who continue intravenous heroin and in those who are heroin dependent but currently not in treatment. METHOD In an open-label multicentre randomised controlled trial, 1015 people with heroin dependence received a variable dose of injectable heroin (n=515) or oral methadone (n=500) for 12 months. Two response criteria, improvement of physical and/or mental health and decrease in illicit drug use, were evaluated in an intent-to-treat analysis. RESULTS Retention was higher in the heroin (67.2%) than in the methadone group (40.0%) and the heroin group showed a significantly greater response on both primary outcome measures. More serious adverse events were found in the heroin group, and were mainly associated with intravenous use. CONCLUSIONS Heroin-assisted treatment is more effective for people with opioid dependence who continue intravenous heroin while on methadone maintenance or who are not enrolled in treatment. Despite a higher risk, it should be considered for treatment resistance under medical supervision.
Collapse
Affiliation(s)
- Christian Haasen
- Centre for Interdisciplinary Addiction Research, Department of Psychiatry, University Medical Centre Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany.
| | | | | | | | | | | |
Collapse
|
20
|
Smyth B, Hoffman V, Fan J, Hser YI. Years of potential life lost among heroin addicts 33 years after treatment. Prev Med 2007; 44:369-74. [PMID: 17291577 PMCID: PMC2039886 DOI: 10.1016/j.ypmed.2006.10.003] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2006] [Revised: 08/12/2006] [Accepted: 10/16/2006] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To examine premature mortality in terms of years of potential life lost (YPLL) among a cohort of long-term heroin addicts. METHOD This longitudinal, prospective study followed a cohort of 581 male heroin addicts in California for more than 33 years. In the latest follow-up conducted in 1996/97, 282 subjects (48.5%) were confirmed as deceased by death certificates. YPLL before age 65 years was calculated by causes of death. Ethnic differences in YPLL were assessed among Whites, Hispanics, and African Americans. RESULTS On average, addicts in this cohort lost 18.3 years (SD=10.7) of potential life before age 65. Of the total YPLL for the cohort, 22.3% of the years lost was due to heroin overdose, 14.0% due to chronic liver disease, and 10.2% to accidents. The total YPLL and YPLL by death cause in addict cohort were significantly higher than that of US population. The YPLL among African Americans was significantly lower than that among Whites or Hispanics. CONCLUSION The YPLL among addicts was much higher than that in the national population; within the cohort, premature mortality was higher among Whites and Hispanics compared to African American addicts.
Collapse
Affiliation(s)
- Breda Smyth
- Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Valerie Hoffman
- Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Jing Fan
- Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Yih-Ing Hser
- Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los Angeles, California
| |
Collapse
|
21
|
|