Testing positive for methadone and either a tricyclic antidepressant or a benzodiazepine is associated with an accidental overdose death: analysis of medical examiner data

Gender differences among persons entering medication treatment for opioid use disorder in the community

BACKGROUND AND OBJECTIVES

We evaluated gender differences among persons initiating medications for opioid use disorder (MOUD).

METHODS

Analyses of baseline assessments for a study evaluating the impact of MOUD on outcomes included: demographics, DSM-5 diagnoses, depression severity, quality of life (QoL), and medication history (N = 125).

RESULTS

When compared to men, women had a greater prevalence of generalized anxiety and posttraumatic stress disorders; and worse psychological QoL. Women were less likely to be prescribed psychiatric medications.

DISCUSSION AND CONCLUSIONS

Women may benefit from tailored multidisciplinary programs with MOUD.

SCIENTIFIC SIGNIFICANCE

This study identified that women with OUD seeking MOUD in the community had greater sedative hypnotic nonprescribed medication use and psychiatric comorbidity than men, all of which can contribute to poorer retention on MOUD and higher risk of morbidity and mortality. Thus, concurrent psychiatric disorder screening and treatment integrated with MOUD may improve retention on MOUD, opioid relapse and overdose for women.

Alprazolam-related deaths in Scotland, 2004-2020

BACKGROUND

The benzodiazepine drug alprazolam, a fast-acting tranquiliser, cannot be prescribed on the National Health Service in the United Kingdom. Illicit alprazolam supply and consumption have increased. Concern about increasing numbers of alprazolam-related fatalities started circulating in 2018. However, statistics on this issue are very limited. This study examined patterns in such mortality in Scotland.

METHODS

Statistics on deaths where alprazolam was mentioned in the 'cause of death' were obtained from official mortality registers. Anonymised Scottish case-level data were obtained. Data were examined in respect of the characteristics of decedents and deaths using descriptive statistics.

RESULTS

Scotland registered 370 deaths in 2004-2020; 366 of these occurred in 2015-2020: most involved males (77.1%); mean age 39.0 (SD 12.6) years. The principal underlying cause of death was accidental poisoning: opiates/opioids (77.9%); sedatives/hypnotics (15.0%). Two deaths involved alprazolam alone. Main drug groups implicated: opiates/opioids (94.8%), 'other benzodiazepines' (67.2%), gabapentinoids (42.9%), stimulants (30.1%), antidepressants (15.0%). Two-thirds (64.2%) involved combinations of central nervous system (CNS) depressants.

DISCUSSION

Alprazolam-related deaths are likely due to an increasing illicit supply. The fall in deaths in 2019-2020 is partially due to increased use of designer benzodiazepines. Treatment for alprazolam dependence is growing. Clinicians need to be aware of continuing recreational alprazolam use. When such consumption occurs with CNS depressants, overdose and death risks increase.

CONCLUSIONS

More awareness of alprazolam contributing to deaths, especially in conjunction with other CNS depressants, is needed by consumers and clinicians. Improved monitoring of illicit supplies could identify emerging issues of medicines' abuse.

Coprescribing of opioids and high-risk medications in the USA: a cross-sectional study with data from national ambulatory and emergency department settings

OBJECTIVE

Describe trends in opioid plus high-risk medication coprescribing in the USA.

DESIGN

Analyses of serial, cross-sectional, nationally representative data of the National Ambulatory Medical Care Survey (NAMCS) over 2007-2016 and the National Hospital Ambulatory Medical Care Survey (NHAMCS) over 2007-2018.

SETTING

US ambulatory (NAMCS) and emergency department (ED, NHAMCS) settings.

PARTICIPANTS

Patient visits in which the patient was 18 years and older with an opioid prescription in the NAMCS or NHAMCS databases.

PRIMARY AND SECONDARY OUTCOME MEASURES

Frequency of opioid plus high-risk medication coprescribing.

RESULTS

From a combined sample of 700 499 visits over 2007-2018, there were 105 720 visits (15.1%) where opioids were prescribed. n=31 825 were from NAMCS and n=73 895 were from NHAMCS. The mean prevalence of coprescription of opioids and high-risk medications for the combined NAMCS and NHAMCS sample was 18.4% in 2007, peaked at 33.2% in 2014 and declined to 23.8% in 2016. Compared with adults receiving opioid prescriptions alone, those coprescribed opioids and high-risk medications were older, more likely female, white and using private or Medicare insurance (p<0.0001).

CONCLUSIONS

Coprescribing is more common in ambulatory than ED settings and has been declining, yet one in four patient visits where opioids were prescribed resulted in coprescribed, high-risk medications in 2016. Efforts and research to help lower the rates of high-risk prescribing are needed.

Misuse of Over the Counter and Prescription Only Medication by Adults Accessing Specialist Treatment Services in the UK: A Narrative Synthesis

Background:

Concerns about the misuse of over the counter (OTC) and prescription only medication (POM) are due to their impact upon physical/mental wellbeing, drug interactions and drug-related deaths. Improving an understanding of the pattern of use by people accessing specialist substance misuse services (SMSs) should enable improvements to treatment provision.

Aim:

To review the literature on the misuse of OTC/POM among adults accessing SMS, including the pattern of use, types of medication and associated characteristics.

Methods:

This review is reported in line with PRISMA. The protocol has been registered on PROSPERO (CRD42020135216) and separately published. A search of Cochrane, OVID Medline, Pubmed, Scopus and Web of Science databases and grey literature was undertaken. Only English language publications outlining OTC/POM misuse by adults in receipt of psychological/pharmacological interventions for substance misuse were included. Two reviewers conducted the title, abstract and full-text reviews using predetermined selection criteria and a piloted data extraction form to ensure a consistent approach. A third reviewer resolved disagreements and the Mixed Methods Appraisal Tool assessed for bias. Ethical approval was not required.

Results:

Thirteen studies with notable heterogeneity were included in the narrative synthesis after non-UK-based and ineligible publications were excluded, from the 143 potentially relevant papers. To reduce bias all studies were included in the analysis and GRADE-CERQual was applied. ‘High confidence’ was identified for all review findings, despite moderate methodological limitations. Antihistamine, benzodiazepine and opioid misuse was mentioned most frequently. Usage patterns and supply sources varied. Adverse consequences and polypharmacy are concerning. Withdrawal symptoms perpetuated misuse, often alongside illicit substance use, comorbid psychiatric/pain disorders and street drug shortages.

Conclusion:

OTC/POM misuse is common amongst adults accessing SMS. A renewed approach to withdrawal management is required. The limited number of studies may impact on generalisability but allowed for a more detailed review. Restricting to UK studies improved relevance due to drug market variations and availability of medicines in different countries. Further UK-based research on OTC/POM misuse in SMS is needed to build upon the current paucity in the published literature.

Surveying Over the Counter and Prescription Only Medication Misuse in Treatment Services During COVID-19

Background:

A greater understanding of Over the Counter (OTC) and Prescription Only Medication (POM) misuse amongst adults accessing substance misuse services (SMS) during COVID-19 is required to identify how SMS can better meet the needs of the people who require treatment.

Aim:

To use a questionnaire to explore OTC/POM misuse during COVID-19 in adults accessing community SMS in England.

Methods:

In 2020 to 2021 anonymous self-administered online/paper questionnaires which collated quantitative and qualitative data were completed. They were piloted for suitability and ethical approval was obtained. Thematic analysis was conducted for qualitative data and chi-square tests used to assess the relationship between quantitative variables.

Results:

Participants were Caucasian (94.6% British), majority male (58.9%), aged 18 to 61 years. Most were prescribed medication for problematic substance use, with a 92.5% self-reported adherence rate. The misuse of benzodiazepines (22.2%) codeine products (30.8%) and pregabalin (14.5%) predominated and 37.5% misused 2 or more medicines. Administration was usually oral and concomitant use of other substances was common: alcohol 44.6% (52% daily), tobacco/vaping 73.2% and illicit substances 58.9%. There were statistically significant associations identified, including between changes during COVID-19 to OTC/POM misuse and illicit use. Only 56 questionnaires were included in the analysis: we believe this low number was because of infection control measures, limited footfall in services, pressures on staff limiting their capacity to distribute the paper questionnaires and reliance upon telephone consultations limiting online distribution. Increasing OTC/POM misuse and obtaining illicit supplies were reported when access to usual supplies were restricted; however, changes to doses/dispensing arrangement liberalisation in response to COVID-19 were positively viewed.

Conclusion:

OTC/POM misuse, including polypharmacy and concomitant use of other substances occurred during COVID-19: SMS need to be vigilant for these issues and mitigate the associated risks for example with harm reduction interventions. Further qualitative research is required to explore the issues identified.

Psychiatric disorders in a population of deceased drug users

PURPOSE

To estimate the prevalence of psychiatric morbidity and dual diagnosis in a population of decedents with positive drug toxicology and evaluate changes over time between 2001-2002 and 2011-2012.

MATERIALS AND METHODS

A total of 520 autopsied drug users with positive toxicology were included in the study from 2001 to 2002 and from 2011 to 2012. Materials included autopsy reports, toxicological screening during autopsy and data from the Danish national health registers, including psychiatric diagnoses from psychiatric hospitals and ambulatory functions, dispensed prescription use from pharmacies and registered treatment for drug use disorders.

RESULTS

In 2001-2002, 63.3% of the decedents had only positive toxicology, 22.5% also had psychiatric morbidity, and 14.2% had a dual diagnosis. In 2011-2012, 56.4% had only positive toxicology, 26.1% also had psychiatric morbidity, and 17.5% had a dual diagnosis. None of the changes were significant. Decedents with only positive toxicology became older at time of death over time; decedents with psychiatric morbidity and a dual diagnosis did not. The prevalence of nonprescribed psychotropic medication, methadone and benzodiazepines increased.

CONCLUSION

Decedents with psychiatric morbidity and dual diagnosis did not increase their lifespan over a 10-year period. Decedents with only positive toxicology increasingly consumed nonprescribed psychotropic medication and may have suffered from undiagnosed psychiatric disorders. The prevalence of prescribed and nonprescribed benzodiazepines and methadone increased and may have contributed to premature mortality.

Opioid and benzodiazepine dispensing and co-dispensing patterns among commercially insured pregnant women in the United States, 2007-2015

BACKGROUND

Little is known about benzodiazepine and opioid-benzodiazepine co-dispensing patterns among pregnant women. Understanding these patterns is necessary to mitigate high-risk medication use during pregnancy. Our objective in this analysis was to evaluate opioid and benzodiazepine dispensing and co-dispensing patterns among commercially insured pregnant women in the United States.

METHODS

This retrospective study used a 10% random sample of commercially insured enrollees from the IQVIA™ Adjudicated Health Plan Claims Data from 2007 to 2015. The study included women (12-55 years of age) with completed pregnancies who had continuous medical and prescription drug coverage from 3 months prior to the date of conception through 3 months post-delivery. We estimated the prevalence of opioid and benzodiazepine dispensing and co-dispensing before, during, and after pregnancy, and evaluated trends in dispensing patterns across the study period (2007-2015) using Cochrane-Armitage tests. Chi-square tests were used to examine differences in demographic and clinical characteristics by dispensing and co-dispensing patterns. Among women that received an opioid or benzodiazepine during pregnancy, logistic regression models were used to quantify the association between sample characteristics and dispensing patterns (co-dispensing vs single dispensing).

RESULTS

Of 168,025 pregnant women that met our inclusion criteria, 10.1% received at least one opioid and 2.0% received at least one benzodiazepine during pregnancy, while 0.5% were co-dispensed these drugs. During the study period (2007 vs 2015), prevalence of opioid dispensing during pregnancy decreased from 11.2 to 8.6% (p <  0.01); while benzodiazepine dispensing increased from 1.3 to 2.9% (p <  0.01), and the prevalence of co-dispensing, while low and stable, increased slightly from 0.39 to 0.44% (p <  0.01). Older age, a higher comorbidity burden, pain diagnosis, anxiety diagnosis, and alcohol, tobacco, and drug use disorders, were all associated with an increased odds of co-dispensing during pregnancy.

CONCLUSIONS

This study provides evidence that while opioid dispensing during pregnancy has decreased in the past decade, benzodiazepine dispensing has increased. The prevalence of opioid-benzodiazepine co-dispensing was rare and remained fairly stable during our study period. Those co-dispensed both drugs had a higher prevalence of adverse birth outcomes. Further research to establish the potentially causal relationship between opioid and benzodiazepine co-dispensing and adverse birth outcomes should be undertaken.

Mortality in an Opioid Treatment Program

This retrospective study examined mortality in an Opioid Treatment Program (OTP) with policies designed to admit and retain patients with as few barriers as possible. Methadone provided in the context of an OTP is known to decrease mortality and morbidity. Historically, patients have been discharged or turned away because of continued substance use. We examined patient deaths over three years in an OTP serving approximately 2400 patients daily. Demographics and causes of death were gathered from electronic health records and medical examiner reports. Pairwise comparisons were used to compare drug poisoning versus non-drug poisoning deaths. There were 155 deaths during the study period. The average age was 54, and half of the participants had positive results on their most recent drug screen. Forty one (26%) died from "drug poisoning." Drug poisoning deaths were more common among patients who: 1) had recent positive drug test results; 2) had documented alprazolam use; 3) were younger; 4) had shorter treatment durations; 5) were female. The majority of deaths were among long-term patients over 50 and were not caused by drug poisoning. These results support keeping patients in treatment despite ongoing drug use, and linking them to appropriate primary care.

Outpatient, combined use of opioid and benzodiazepine medications in the United States, 1993-2014

The combined use of opioid and benzodiazepine medications increases the risk of hazardous effects, such as respiratory depression. Although recent increases in outpatient use of opioid prescriptions have been documented, there are limited data regarding rates and correlates of combined opioid and benzodiazepines among adults in outpatient settings. Our objective was to examine annual trends in outpatient visits including opioids, benzodiazepines, and their combination among adults as well as clinical and demographic correlates. We used data from the 1993–2014 National Ambulatory Medical Care Survey (NAMCS) among non-elderly (i.e., ages 18–64 years) adults to examine the probability of a visit including an opioid, benzodiazepine, or their combination, in addition to clinical and demographic correlates. From 1993 to 2014, benzodiazepines-with-opioids visits increased from 9.8 to 62.5 (OR = 9.23, 95% CI = 5.45–15.65) per 10,000 visits. Highest-represented groups among benzodiazepines-with-opioids visits were older (50–64 years) (49.1%), white (88.8%), commercially insured (58.0%) patients during their first visit (87.6%) to a primary-care physician (41.9%). We identified a significant increase in the outpatient co-prescription of opioids and benzodiazepines, notably among adults aged 50–64 years during primary-care visits. Educational and policy changes to provide alternatives to benzodiazepine-with-opioid co-prescription and limiting opioid prescription to pain specialists may reduce rates of this potentially hazardous combination.

•

Current guidelines for prescribing opioids recommend against co-administration with benzodiazepines

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Concurrent use of opioids and benzodiazepines increases the risk of overdose, respiratory depression, and death.

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We examined 22 years of outpatient prescribing patterns of opioids and benzodiazepines using a survey of US physicians.

•

Over this period, visits with both opioids and benzodiazepines increased from roughly 9.8 to 62.5 per 10,000 visits.

•

These visits were more likely among older (50–64 years), white, privately insured patients with a low-back pain diagnosis.

High enhancer, downer, withdrawal helper: Multifunctional nonmedical benzodiazepine use among young adult opioid users in New York City

BACKGROUND

Benzodiazepines are a widely prescribed psychoactive drug; in the U.S., both medical and nonmedical use of benzodiazepines has increased markedly in the past 15 years. Long-term use can lead to tolerance and dependence, and abrupt withdrawal can cause seizures or other life-threatening symptoms. Benzodiazepines are often used nonmedically in conjunction with other drugs, and with opioids in particular-a combination that can increase the risk for fatal and non-fatal overdose. This mixed-methods study examines nonmedical use of benzodiazepines among young adults in New York City and its relationship with opioid use.

METHODS

For qualitative analysis, 46 90-minute semi-structured interviews were conducted with young adult opioid users (ages 18-32). Interviews were transcribed and coded for key themes. For quantitative analysis, 464 young adult opioid users (ages 18-29) were recruited using Respondent-Driven Sampling and completed structured interviews. Benzodiazepine use was assessed via a self-report questionnaire that included measures related to nonmedical benzodiazepine and opioid use.

RESULTS

Participants reported using benzodiazepines nonmedically for a wide variety of reasons, including: to increase the high of other drugs; to lessen withdrawal symptoms; and to come down from other drugs. Benzodiazepines were described as readily available and cheap. There was a high prevalence (93%) of nonmedical benzodiazepine use among nonmedical opioid users, with 57% reporting regular nonmedical use. In bivariate analyses, drug-related risk behaviours such as polysubstance use, drug binging, heroin injection and overdose were strongly associated with regular nonmedical benzodiazepine use. In multivariate analysis, growing up in a middle-income household (earning between $51,000 and $100,000 annually), lifetime overdose experience, having ever used cocaine regularly, having ever been prescribed benzodiazepines, recent drug binging, and encouraging fellow drug users to use benzodiazepines to cope with opioid withdrawal were consistently strong predictors of regular nonmedical benzodiazepine use.

CONCLUSION

Nonmedical benzodiazepine use may be common among nonmedical opioid users due to its drug-related multi-functionality. Harm reduction messages should account for the multiple functions benzodiazepines serve in a drug-using context, and encourage drug users to tailor their endorsement of benzodiazepines to peers to include safer alternatives.

Need and utility of a polyethylene glycol marker to ensure against urine falsification among heroin users

BACKGROUND

Deceptive methods of falsifying urine samples are of concern for anyone who relies on accurate urine toxicology results. A novel method to combat these efforts utilizes polyethylene glycol (PEG) markers administered orally prior to providing a urine sample. By using various PEG combinations to create a tracer capsule of unique composition, each urine sample can be matched to that individual. The goal of this study was to determine the effectiveness of using the PEG marker system among active heroin users screening for research studies.

METHODS

Upon each screening visit, participants (N=55) were randomized to provide an unobserved urine sample, or the PEG tracer procedure was used. LCMS analysis was used to distinguish the PEG combinations, and allowed us to provide a unique qualitative analysis of patterns of drug use (N=168, total urine specimens).

RESULTS

The unique composition of the tracer capsules was accurately detected in 83.5% of the urine specimens. Analyses of inconsistencies implicated a number of possible attempts at fraudulence (11.4%) and investigator/lab error (5.1%). Among this sample, the concurrent use of multiple classes of psychoactive drugs was more common than not, though concomitant drug use was often underreported.

CONCLUSION

Urine drug testing should be the minimum standard for obtaining information about drug use as self-report was unreliable even in a situation where there were no perceived adverse consequences for full disclosure. In cases where there are significant pressures for individuals to falsify these data, more protective collection methods such as the PEG marker system should be considered.

Parent and Metabolite Opioid Drug Concentrations in Unintentional Deaths Involving Opioid and Benzodiazepine Combinations

Effects of benzodiazepines on postmortem opioid parent and parent/metabolite blood concentration ratios were determined for fentanyl-, hydrocodone-, methadone-, or oxycodone-related accidental deaths. These opioids are partially metabolized by the CYP3A4 enzyme system, which is also affected by diazepam and alprazolam. Opioid/metabolite combinations examined were as follows: fentanyl/norfentanyl, hydrocodone/dihydrocodeine, methadone/EDDP, and oxycodone/oxymorphone. Parent opioid concentrations were analyzed for 877 deaths. Parent/metabolite concentration ratios were analyzed for 349 deaths, excluding cases with co-intoxicants present known to interfere with opioid elimination. Alprazolam in combination with diazepam significantly decreased median hydrocodone concentrations by 48% (p = 0.01) compared to hydrocodone alone. The methadone parent/metabolite concentration ratio was reduced by 35% in the presence of diazepam compared to methadone alone (p = 0.03). Benzodiazepines did not statistically significantly affect fentanyl or oxycodone concentrations. Possible factors affecting opioid concentrations and possible toxicity development, including any differential effects on specific opioids, should continue to be explored.

A Review of Opioid Overdose Prevention and Naloxone Prescribing: Implications for Translating Community Programming Into Clinical Practice

BACKGROUND

As physicians have increased opioid prescribing, overdose deaths from pharmaceutical opioids have substantially increased in the United States. Naloxone hydrochloride (naloxone), an opioid antagonist, is the standard of care for treatment of opioid induced respiratory depression. Since 1996, community-based programs have offered overdose prevention education and distributed naloxone for bystander administration to people who use opioids, particularly heroin. There is growing interest in translating overdose education and naloxone distribution (OEND) into conventional medical settings for patients who are prescribed pharmaceutical opioids. For this review, we summarized and classified existing publications on overdose education and naloxone distribution to identify evidence of effectiveness and opportunities for translation into conventional medical settings.

METHODS

For this review, we searched English language PubMed for articles on naloxone based on primary data collection from humans, including feasibility studies, program evaluations, surveys, qualitative studies, and studies comparing the effectiveness of different routes of naloxone administration. We also included cost-effectiveness studies.

RESULTS

We identified 41 articles that represented 5 categories: evaluations of OEND programs, effects of OEND programs on experiences and attitudes of participants, willingness of medical providers to prescribe naloxone, comparisons of different routes of naloxone administration, and the cost-effectiveness of naloxone.

CONCLUSIONS

Existing research suggests that people who are at risk for overdose and other bystanders are willing and able to be trained to prevent overdoses and administer naloxone. Counseling patients about the risks of opioid overdose and prescribing naloxone is an emerging clinical practice that may reduce fatalities from overdose while enhancing the safe prescribing of opioids.

Polydrug abuse: a review of opioid and benzodiazepine combination use

This paper reviews studies examining the pharmacological interactions and epidemiology of the combined use of opioids and benzodiazepines (BZDs). A search of English language publications from 1970 to 2012 was conducted using PubMed and PsycINFO(®). Our search found approximately 200 articles appropriate for inclusion in this paper. While numerous reports indicate that the co-abuse of opioids and BZDs is ubiquitous around the world, the reasons for the co-abuse of these medications are not entirely clear. Though the possibility remains that opioid abusers are using BZDs therapeutically to self-medicate anxiety, mania or insomnia, the data reviewed in this paper suggest that BZD use is primarily recreational. For example, co-users report seeking BZD prescriptions for the purpose of enhancing opioid intoxication or "high," and use doses that exceed the therapeutic range. Since there are few clinical studies investigating the pharmacological interaction and abuse liability of their combined use, this hypothesis has not been extensively evaluated in clinical settings. As such, our analysis encourages further systematic investigation of BZD abuse among opioid abusers. The co-abuse of BZDs and opioids is substantial and has negative consequences for general health, overdose lethality, and treatment outcome. Physicians should address this important and underappreciated problem with more cautious prescribing practices, and increased vigilance for abusive patterns of use.

Survey of methadone-drug interactions among patients of methadone maintenance treatment program in Taiwan

BACKGROUND

Although methadone has been used for the maintenance treatment of opioid dependence for decades, it was not introduced in China or Taiwan until 2000s. Methadone-drug interactions (MDIs) have been shown to cause many adverse effects. However, such effects have not been scrutinized in the ethnic Chinese community.

METHODS

The study was performed in two major hospitals in southern Taiwan. A total of 178 non-HIV patients aged ≥ 20 years who had participated in the Methadone Maintenance Treatment Program (MMTP) ≥ 1 month were recruited. An MDI is defined as concurrent use of drug(s) with methadone that may result in an increase or decrease of effectiveness and/or adverse effect of methadone. To determine the prevalence and clinical characteristics of MDIs, credible data sources, including the National Health Insurance (NHI) database, face-to-face interviews, medical records, and methadone computer databases, were linked for analysis. Socio-demographic and clinical factors associated with MDIs and co-medications were also examined.

RESULTS

128 (72%) MMTP patients took at least one medication. Clinically significant MDIs included withdrawal symptoms, which were found among MMTP patients co-administered with buprenorphine or tramadol; severe QTc prolongation effect, which might be associated with use of haloperidol or droperidol; and additive CNS and respiratory depression, which could result from use of methadone in combination with chlorpromazine or thioridazine. Past amphetamine use, co-infection with hepatitis C, and a longer retention in the MMTP were associated with increased odds of co-medication. Among patients with co-medication use, significant correlates of MDIs included the male gender and length of co-medication in the MMTP.

CONCLUSIONS

The results demonstrate clinical evidence of significant MDIs among MMTP patients. Clinicians should check the past medical history of MMTP clients carefully before prescribing medicines. Because combinations of methadone with other psychotropic or opioid medications can affect treatment outcomes or precipitate withdrawal symptoms, clinicians should be cautious when prescribing these medications to MMTP patients and monitor the therapeutic effects and adverse drug reactions. Although it is difficult to interconnect medical data from different sources for the sake of privacy protection, the incumbent agency should develop pharmacovigilant measures to prevent the MDIs from occurring. Physicians are also advised to check more carefully on the medication history of their MMTP patients.

Heavy use versus less heavy use of sedatives among non-medical sedative users: Characteristics and correlates

Non-medical use of sedatives is an ongoing problem. However, very little is known about the characteristics of individuals who use sedatives non-medically, or the motives behind such use. The present analysis, involving a sample of individuals reporting non-medical use of sedatives in the past 12 months (N=188), examined the relationship between socio-demographic variables, past-year use of other licit and illicit drugs, type of non-medical use (use in ways other than as prescribed, use when not prescribed, or both), motives, and past 12-month sedative use. Past 12-month sedative use was dichotomized as Heavy Use (>90 pills in past 12 months) and Less Heavy Use (≤90 pills), using a median split. Multivariate logistic regression analyses indicated that Heavy Use of sedatives was significantly associated with positive diagnoses for sedative use disorder and prescription opioid use disorder, a higher number of motives for sedative use, and reporting 'sedative use in ways other than as prescribed' and 'both forms of non-medical use, namely, other than as prescribed, and when not prescribed,' compared to non-prescribed use. Although in univariate analyses a positive diagnosis for past 12-month cocaine use disorder, and individual motives for sedative use such as 'to get high' and 'for pain relief', significantly predicted past 12-month Heavy Use, their effects diminished and became non-significant after adjusting for other covariates. Findings underscore the need for considering differential risk factors in tailoring preventive interventions for reducing non-medical sedative use.

Staff attitudes and the associations with treatment organisation, clinical practices and outcomes in opioid maintenance treatment

BACKGROUND

In opioid maintenance treatment (OMT) there are documented treatment differences both between countries and between OMT programmes. Some of these differences have been associated with staff attitudes. The aim of this study was to 1) assess if there were differences in staff attitudes within a national OMT programme, and 2) investigate the associations of staff attitudes with treatment organisation, clinical practices and outcomes.

METHODS

This study was a cross-sectional multicentre study. Norwegian OMT staff (n = 140) were invited to participate in this study in 2007 using an instrument measuring attitudes towards OMT. The OMT programme comprised 14 regional centres. Data describing treatment organisation, clinical practices and patient outcomes in these centres were extracted from the annual OMT programme assessment 2007. Centres were divided into three groups based upon mean attitudinal scores and labelled; "rehabilitation-oriented", "harm reduction-oriented" and "intermediate" centres.

RESULTS

All invited staff (n = 140) participated. Staff attitudes differed between the centres. "Rehabilitation-oriented" centres had smaller caseloads, more frequent urine drug screening and increased case management (interdisciplinary meetings). In addition these centres had less drug use and more social rehabilitation among their patients in terms of long-term living arrangements, unemployment, and social security benefits as main income. "Intermediate" centres had the lowest treatment termination rate.

CONCLUSIONS

This study identified marked variations in staff attitudes between the regional centres within a national OMT programme. These variations were associated with measurable differences in caseload, intensity of case management and patient outcomes.

Clinical Characteristics of Central European and North American Samples of Pregnant Women Screened for Opioid Agonist Treatment

BACKGROUND

Little comparable information is available regarding clinical characteristics of opioid-dependent women from different countries. In the present study, women from the USA, Canada and a Central European country, Austria, screened for participation in the Maternal Opioid Treatment Human Experimental Research study, were compared with respect to their demographic and addiction histories.

METHODS

Pregnant women (n = 1,074) were screened for study participation using uniformed clinical criteria and instruments. The screening results were compared with regard to exclusion, demographics, drug use, and psychosocial and treatment histories.

RESULTS

Compared to the screened US and Canadian women, Austrian women were more likely to be younger (p < 0.001), white (p < 0.001), had significantly lower levels of educational attainment (p < 0.001), were less likely to use opioids daily (p < 0.001) and more likely to have been prescribed buprenorphine (p < 0.001). Compared to both rural and urban US groups, the Austrian group was less likely to have legal issues (p < 0.001) and was younger when first prescribed agonist medication (p < 0.001).

CONCLUSION

The differences between North American and European groups may offer unique insights concerning treatment and pregnancy outcomes for opioid-dependent pregnant women.

Methadone: a new old drug with promises and pitfalls

Although methadone is not a new medication, its use in pain management has increased rapidly over the past decade. This article reviews the unique pharmacologic properties of methadone, including its long-acting nature, highly variable clearance rate, and its antagonism of the N-methyl-D-aspartate receptor. We discuss potential benefits and risks of methadone over other opioid medications. Preclinical studies suggest methadone may reduce abuse potential, tolerance development, and sensitization of nociceptive pathways. Pharmacologic properties of methadone suggest potential greater risk of dangerous or fatal side effects from overdose, QT interval prolongation, and drug interactions. However, clinical studies have yet to confirm that methadone produces either better clinical outcomes or higher rates of adverse events than other opioid analgesics. Clinicians who understand the special properties of methadone and follow recommended precautionary prescribing and monitoring practices can safely and effectively use methadone for pain treatment.

An in vitro approach to potential methadone metabolic-inhibition interactions

OBJECTIVE

The aim of this study was to assess the drug interaction potential of psychotropic medication on methadone N-demethylation using cDNA-expressed cytochrome P450 CYP enzymes.

METHODS

Methadone was incubated with various drugs (n = 10) and cDNA-expressed CYP3A4, CYP2D6, CYP2B6, CYP2C19 and CYP1A2 enzymes to screen for their inhibition potency. The nature of enzyme selective activity for inhibition was further investigated for potent inhibitors. To test for a mechanism-based component in inhibition, all substances were tested with preincubation and without. 2-Ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP) concentration was determined by liquid chromatography/tandem mass spectrometry following liquid/liquid extraction.

RESULTS

Formation of EDDP was catalysed by CYP3A4, CYP2D6 and CYP2C19. The N-demethylation of methadone was preferentially inhibited by amitriptyline, buprenorphine, methylenedioxymethamphetamine (MDMA) and zolpidem. Both amitriptyline and buprenorphine were strong, reversible inhibitors of CYP3A4. Similarly, amitriptyline and MDMA were identified as inhibitors of CYP2D6. Zolpidem revealed a mechanism-based inhibition of CYP3A4.

CONCLUSION

Amitriptyline, MDMA and zolpidem are likely to slow down conversion of methadone and to increase its area under the curve (AUC). A consideration of the in vitro evidence of drug-methadone interactions should help to improve patient care during methadone maintenance treatment.