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Ling R, White B, Roberts J, Cretikos M, Howard MV, Haber PS, Lintzeris N, Reeves P, Dunlop AJ, Searles A. Depot buprenorphine as an opioid agonist therapy in New South Wales correctional centres: a costing model. BMC Health Serv Res 2022; 22:1326. [PMID: 36348369 PMCID: PMC9644557 DOI: 10.1186/s12913-022-08687-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 10/10/2022] [Indexed: 11/09/2022] Open
Abstract
Background In 2019 daily liquid methadone and sublingual buprenorphine-naloxone were primary opioid agonist treatments for correctional centres in New South Wales, Australia. However, both had significant potential for diversion to other patients, and their daily administration was resource intensive. An alternative treatment in the form of subcutaneous depot buprenorphine became a viable option following a safety trial in 2020 – the UNLOC-T study. Depot preparation demonstrated advantages over current treatments as more difficult to divert and requiring fewer administrations. This paper reports the results of economic modelling of staffing costs in medication administration comparing depot buprenorphine, methadone, and sublingual buprenorphine provision in UNLOC-T trial facilities. Methods The costing study adopted a micro-costing approach involving the synthesis of cost data from the UNLOC-T clinical trial as well as data collected from Justice Health and Forensic Mental Health Network records. Labour and materials data were collected during site observations and interviews. Costs were calculated from two payer perspectives: a) the New South Wales (state) government which funds custodial and health services; and b) the Australian Commonwealth government, which pays for medications. The analysis compared the monthly-per-patient cost for each of the three medications in trial-site facilities during July 2019. This was followed by simulation of depot buprenorphine implementation across the study population. Costs associated with medical assessment and reviews were excluded. Results The monthly-per-patient New South Wales government service costs of depot buprenorphine, methadone and sublingual buprenorphine were: $151, $379 and $1,529 respectively while Commonwealth government medication costs were $434, $80 and $525. The implementation simulation found that service costs of depot buprenorphine declined as patients transitioned from weekly to monthly administration. Costs of treatment using the other medications increased as patient numbers decreased alongside fixed costs. At 12 months, monthly-per-patient service costs for depot buprenorphine, methadone and sublingual buprenorphine—which would be completely phased out by month 13—were $92, $530 and $2,162 respectively. Conclusions Depot buprenorphine was consistently the least costly of the treatment options. Future modelling could allow for dynamic patient populations and downstream impacts for participants and the state health system. Trial registration ACTRN12618000942257. Registered 4 June 2018.
Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08687-8.
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Wilson HHK, Schulz M, Mills L, Lintzeris N. Feasibility and outcomes of a general practice and specialist alcohol and other drug collaborative care program in Sydney, Australia. Aust J Prim Health 2022; 28:158-163. [PMID: 35105435 DOI: 10.1071/py20197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 05/25/2021] [Indexed: 11/23/2022]
Abstract
Alcohol and other drug (AoD) use is an important health and community issue and may be positively affected by collaborative care programs between specialist AoD services and general practice. This paper describes the feasibility, model of care and patient outcomes of a pilot general practice and specialist AoD (GP-AoD) collaborative care program, in Sydney, Australia, based on usual care data, the minimum data set, service utilisation information and the Australian Treatment Outcome Profile (ATOP), a patient-reported outcome measure. There were 367 referrals to the collaborative care program. GPs referred 210 patients, whereas the AoD service referred 157 patients. Most GP referrals (91.9%) were for AoD problems, whereas nearly half the AoD service referrals were for other issues. The primary drugs of concern in the GP group were either opioids or non-opioids (mostly alcohol). The AoD service-referred patients were primarily using opioids. An ATOP was completed for 152 patients. At the time of referral, those in the GP-referred non-opioid group were significantly less likely to be abstinent, used their primary drug of concern more days and were more likely to be employed (all P < 0.001). A second ATOP was completed for 93 patients. These data showed a significant improvement in the number of days the primary drug of concern was used (P = 0.026) and trends towards abstinence, improved quality of life and physical and psychological well-being for patients in the program. There are few studies of GP-AoD collaborative care programs and nothing in the Australian context. This study suggests that GP-AoD collaborative care programs in Australia are feasible and improve drug use.
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Affiliation(s)
- H H K Wilson
- Drug & Alcohol Services, South East Sydney Local Health District, 591 South Dowling Street, Surry Hills, NSW 2010, Australia; and School of Public Health and Community Medicine, UNSW Sydney, High Street, Kensington, NSW 2052, Australia; and Corresponding author
| | - M Schulz
- Drug & Alcohol Services, South East Sydney Local Health District, 591 South Dowling Street, Surry Hills, NSW 2010, Australia
| | - L Mills
- Drug & Alcohol Services, South East Sydney Local Health District, 591 South Dowling Street, Surry Hills, NSW 2010, Australia; and Division Addiction Medicine, University of Sydney, NSW 2006, Australia
| | - N Lintzeris
- Drug & Alcohol Services, South East Sydney Local Health District, 591 South Dowling Street, Surry Hills, NSW 2010, Australia; and Division Addiction Medicine, University of Sydney, NSW 2006, Australia
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Grimison P, Mersiades A, Kirby A, Lintzeris N, Morton R, Haber P, Olver I, Walsh A, McGregor I, Cheung Y, Tognela A, Hahn C, Briscoe K, Aghmesheh M, Fox P, Abdi E, Clarke S, Della-Fiorentina S, Shannon J, Gedye C, Begbie S, Simes J, Stockler M. Oral THC:CBD cannabis extract for refractory chemotherapy-induced nausea and vomiting: a randomised, placebo-controlled, phase II crossover trial. Ann Oncol 2020; 31:1553-1560. [DOI: 10.1016/j.annonc.2020.07.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 07/14/2020] [Accepted: 07/27/2020] [Indexed: 10/23/2022] Open
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Mersiades A, Tognela A, Haber P, Stockler M, Lintzeris N, Simes J, McGregor I, Olver I, Allsop D, Gedye C, Kirby A, Morton R, Briscoe K, Fox P, Aghmesheh M, Wong N, Bhardwaj A, Tran A, Hahn C, Grimison P. Pilot and definitive randomised double-blind placebo-controlled trials evaluating an oral cannabinoid-rich THC/CBD cannabis extract for secondary prevention of chemotherapy-induced nausea and vomiting (CINV). Ann Oncol 2018. [DOI: 10.1093/annonc/mdy300.119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Suraev A, Lintzeris N, Stuart J, Kevin RC, Blackburn R, Richards E, Arnold JC, Ireland C, Todd L, Allsop DJ, McGregor IS. Composition and Use of Cannabis Extracts for Childhood Epilepsy in the Australian Community. Sci Rep 2018; 8:10154. [PMID: 29977078 PMCID: PMC6033872 DOI: 10.1038/s41598-018-28127-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 06/04/2018] [Indexed: 12/20/2022] Open
Abstract
Recent surveys suggest that many parents are using illicit cannabis extracts in the hope of managing seizures in their children with epilepsy. In the current Australian study we conducted semi-structured interviews with families of children with diverse forms of epilepsy to explore their attitudes towards and experiences with using cannabis extracts. This included current or previous users of cannabis extracts to treat their child's seizures (n = 41 families), and families who had never used (n = 24 families). For those using cannabis, extracts were analysed for cannabinoid content, with specific comparison of samples rated by families as "effective" versus those rated "ineffective". Results showed that children given cannabis extracts tended to have more severe epilepsy historically and had trialled more anticonvulsants than those who had never received cannabis extracts. There was high variability in the cannabinoid content and profile of cannabis extracts rated as "effective", with no clear differences between extracts perceived as "effective" and "ineffective". Contrary to family's expectations, most samples contained low concentrations of cannabidiol, while Δ9-tetrahydrocannabinol was present in nearly every sample. These findings highlight profound variation in the illicit cannabis extracts being currently used in Australia and warrant further investigations into the therapeutic value of cannabinoids in epilepsy.
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Affiliation(s)
- A Suraev
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - N Lintzeris
- Addiction Medicine, Central Clinical School, Faculty of Medicine, The University of Sydney, Sydney, 2006, Australia
- The Langton Centre, Drug and Alcohol Services, South East Sydney Local Health District, NSW Health, Surry Hills, 2010, Australia
| | - J Stuart
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - R C Kevin
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - R Blackburn
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - E Richards
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - J C Arnold
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
- Department of Pharmacology, Faculty of Medicine, University of Sydney, Sydney, NSW, 2006, Australia
| | - C Ireland
- Epilepsy Action Australia, Sydney, Australia
| | - L Todd
- Epilepsy Action Australia, Sydney, Australia
| | - D J Allsop
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia
| | - I S McGregor
- The Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, The University of Sydney, Sydney, 2050, Australia.
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Lovell ME, Bruno R, Johnston J, Matthews A, McGregor I, Allsop DJ, Lintzeris N. Cognitive, physical, and mental health outcomes between long-term cannabis and tobacco users. Addict Behav 2018; 79:178-188. [PMID: 29291509 DOI: 10.1016/j.addbeh.2017.12.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 11/17/2017] [Accepted: 12/07/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Cannabis intoxication adversely affects health, yet persistent effects following short-term abstinence in long-term cannabis users are unclear. This matched-subjects, cross-sectional study compared health outcomes of long-term cannabis and long-term tobacco-only users, relative to population norms. METHODS Nineteen long-term (mean 32.3years of use, mean age 55.7years), abstinent (mean 15h) cannabis users and 16 long-term tobacco users (mean 37.1years of use, mean age 52.9years), matched for age, educational attainment, and lifetime tobacco consumption, were compared on measures of learning and memory, response inhibition, information-processing, sustained attention, executive control, and mental and physical health. RESULTS Cannabis users exhibited poorer overall learning and delayed recall and greater interference and forgetting than tobacco users, and exhibited poorer recall than norms. Inhibition and executive control were similar between groups, but cannabis users had slower reaction times during information processing and sustained attention tasks. Cannabis users had superior health satisfaction and psychological, somatic, and general health than tobacco users and had similar mental and physical health to norms whilst tobacco users had greater stress, role limitations from emotional problems, and poorer health satisfaction. CONCLUSIONS Long-term cannabis users may exhibit deficits in some cognitive domains despite short-term abstinence and may therefore benefit from interventions to improve cognitive performance. Tobacco alone may contribute to adverse mental and physical health outcomes, which requires appropriate control in future studies.
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Affiliation(s)
- M E Lovell
- School of Medicine (Psychology), University of Tasmania, Hobart, Tasmania 7000, Australia.
| | - R Bruno
- School of Medicine (Psychology), University of Tasmania, Hobart, Tasmania 7000, Australia
| | - J Johnston
- University Centre for Rural Health - North Coast, University of Sydney, Lismore, New South Wales 2480, Australia
| | - A Matthews
- School of Medicine (Psychology), University of Tasmania, Hobart, Tasmania 7000, Australia
| | - I McGregor
- Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, Brain and Mind Centre, University of Sydney, New South Wales 2006, Australia
| | - D J Allsop
- Lambert Initiative for Cannabinoid Therapeutics, School of Psychology, Brain and Mind Centre, University of Sydney, New South Wales 2006, Australia
| | - N Lintzeris
- Discipline of Addictive Medicine, Sydney Medical School, University of Sydney, Sydney, New South Wales 2006, Australia; The Langton Centre, South East Sydney Local Health District (SESLHD), Drug and Alcohol Services, 2010, Australia
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Luckett T, Phillips J, Lintzeris N, Allsop D, Lee J, Solowij N, Martin J, Lam L, Aggarwal R, McCaffrey N, Currow D, Chye R, Lovell M, McGregor I, Agar M. Clinical trials of medicinal cannabis for appetite-related symptoms from advanced cancer: a survey of preferences, attitudes and beliefs among patients willing to consider participation. Intern Med J 2016; 46:1269-1275. [DOI: 10.1111/imj.13224] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 08/02/2016] [Accepted: 08/06/2016] [Indexed: 11/27/2022]
Affiliation(s)
- T. Luckett
- Centre for Cardiovascular and Chronic Care, Faculty of Health; University of Technology Sydney; Sydney New South Wales Australia
| | - J. Phillips
- Centre for Cardiovascular and Chronic Care, Faculty of Health; University of Technology Sydney; Sydney New South Wales Australia
| | - N. Lintzeris
- Discipline of Addiction Medicine, Central Clinical School; Sydney Medical School; Sydney New South Wales Australia
- Drug and Alcohol Services; South East Sydney Local Health District, NSW Health; Sydney New South Wales Australia
| | - D. Allsop
- School of Psychology; The University of Sydney; Sydney New South Wales Australia
| | - J. Lee
- Palliative Care; Concord Repatriation General Hospital; Sydney New South Wales Australia
| | - N. Solowij
- School of Psychology; University of Wollongong; Wollongong New South Wales Australia
| | - J. Martin
- Department of Clinical Pharmacology, School of Medicine and Public Health; University of Newcastle; Newcastle New South Wales Australia
| | - L. Lam
- Centre for Cardiovascular and Chronic Care, Faculty of Health; University of Technology Sydney; Sydney New South Wales Australia
| | - R. Aggarwal
- Palliative Care, Liverpool Cancer Therapy Centre; Liverpool Hospital; Sydney New South Wales Australia
| | - N. McCaffrey
- Palliative and Supportive Services; Flinders University; Adelaide South Australia Australia
| | - D. Currow
- Palliative and Supportive Services; Flinders University; Adelaide South Australia Australia
| | - R. Chye
- Sacred Heart Supportive and Palliative Care; St Vincent's Hospital; Sydney New South Wales Australia
| | - M. Lovell
- Palliative Care, Greenwich Hospital; HammondCare; Sydney New South Wales Australia
- Northern Clinical School, Sydney Medical School; HammondCare; Sydney New South Wales Australia
| | - I. McGregor
- Department of Psychopharmacology, Faculty of Science; The University of Sydney; Sydney New South Wales Australia
| | - M. Agar
- Centre for Cardiovascular and Chronic Care, Faculty of Health; University of Technology Sydney; Sydney New South Wales Australia
- The Ingham Institute of Applied Medical Research; Sydney New South Wales Australia
- South Western Sydney Clinical School; University of New South Wales; Sydney New South Wales Australia
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Hoban B, Larance B, Gisev N, Nielsen S, Cohen M, Bruno R, Shand F, Lintzeris N, Hall W, Farrell M, Degenhardt L. The use of paracetamol (acetaminophen) among a community sample of people with chronic non-cancer pain prescribed opioids. Int J Clin Pract 2015; 69:1366-76. [PMID: 26268890 DOI: 10.1111/ijcp.12716] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 07/22/2015] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The regular use of simple analgesics in addition to opioids such as paracetamol (or acetaminophen) is recommended for persistent pain to enhance analgesia. Few studies have examined the frequency and doses of paracetamol among people with chronic non-cancer pain including use above the recommended maximum daily dose. AIMS To assess (i) the prevalence of paracetamol use among people with chronic non-cancer pain prescribed opioids, (ii) assess the prevalence of paracetamol use above the recommended maximum daily dose and (iii) assess correlates of people who used paracetamol above the recommended maximum daily dose including: age, gender, income, education, pain severity and interference, use of paracetamol/opioid combination analgesics, total opioid dose, depression, anxiety, pain self-efficacy or comorbid substance use, among people prescribed opioids for chronic non-cancer pain. METHODS This study draws on baseline data collected for the Pain and Opioids IN Treatment (POINT) study and utilises data from 962 interviews and medication diaries. The POINT study is national prospective cohort of people with chronic non-cancer pain prescribed opioids. Participants were recruited from randomly selected pharmacies across Australia. RESULTS Sixty-three per cent of the participants had used paracetamol in the past week (95% CI = 59.7-65.8). Among the paracetamol users 22% (95% CI = 19.3-24.6) had used paracetamol/opioid combination analgesics and 4.8% (95% CI = 3.6-6.3) had used paracetamol above the recommended maximum daily dose (i.e. > 4000 mg/day). Following binomial logistic regression (χ(2) = 25.98, df = 10, p = 0.004), people who had taken above the recommended maximum daily dose were less likely to have low income (AOR = 0.52, 95% CI = 0.27-0.99), more likely to use paracetamol/opioid combination analgesics (AOR = 2.01, 95% CI = 1.02-3.98) and more likely to take a higher opioid dose (AOR = 1.00, 95% CI = 1.00-1.01). CONCLUSION The majority of people with chronic non-cancer pain prescribed opioids report using paracetamol appropriately. High income, use of paracetamol/opioid combination analgesics and higher opioid dose were independently associated with paracetamol use above the recommended maximum daily dose.
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Affiliation(s)
- B Hoban
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - B Larance
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - N Gisev
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - S Nielsen
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
- The Langton Centre, South East Sydney Local Health District (SESLHD), Drug and Alcohol Services, Surry Hills, NSW, Australia
| | - M Cohen
- St Vincent's Clinical School, UNSW Australia, Darlinghurst, NSW, Australia
| | - R Bruno
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
- School of Psychology, University of Tasmania, Hobart, TAS, Australia
| | - F Shand
- Black Dog Institute, Prince of Wales Hospital, Randwick, NSW, Australia
| | - N Lintzeris
- The Langton Centre, South East Sydney Local Health District (SESLHD), Drug and Alcohol Services, Surry Hills, NSW, Australia
- Sydney Medical School, Sydney University, Camperdown, NSW, Australia
| | - W Hall
- Centre for Youth Substance Abuse Research, University of Queensland, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - M Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - L Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
- School of Population and Global Health, University of Melbourne, Parkville, VIC, Australia
- Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, VIC, Australia
- Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
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Allsop DJ, Lintzeris N, Copeland J, Dunlop A, McGregor IS. Cannabinoid replacement therapy (CRT): Nabiximols (Sativex) as a novel treatment for cannabis withdrawal. Clin Pharmacol Ther 2015; 97:571-4. [DOI: 10.1002/cpt.109] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 03/05/2015] [Indexed: 11/08/2022]
Affiliation(s)
- DJ Allsop
- Psychopharmacology Laboratory; School of Psychology, Faculty of Science, University of Sydney; NSW Australia
- Discipline of Addiction Medicine, Faculty of Medicine; University of Sydney; NSW Australia
| | - N Lintzeris
- Discipline of Addiction Medicine, Faculty of Medicine; University of Sydney; NSW Australia
- Drug and Alcohol Services, South East Sydney Local Health District, New South Wales Health; NSW Australia
| | - J Copeland
- National Cannabis Prevention and Information Centre; UNSW Medicine; Australia
| | - A Dunlop
- Drug & Alcohol Clinical Services; Hunter New England Local Health District, New South Wales Ministry of Health; Australia
- School of Medicine and Public Health, Faculty of Health, University of Newcastle; Australia
| | - IS McGregor
- Psychopharmacology Laboratory; School of Psychology, Faculty of Science, University of Sydney; NSW Australia
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Nielsen S, Roxburgh A, Bruno R, Lintzeris N, Jefferson A, Degenhardt L. Changes in non-opioid substitution treatment episodes for pharmaceutical opioids and heroin from 2002 to 2011. Drug Alcohol Depend 2015; 149:212-9. [PMID: 25707708 DOI: 10.1016/j.drugalcdep.2015.02.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 01/27/2015] [Accepted: 02/03/2015] [Indexed: 01/28/2023]
Abstract
BACKGROUND There has been a well-documented increase in the non-medical use of pharmaceutical opioids (PO) worldwide. However, there has been little detailed examination of treatment demand, or the characteristics of those presenting for treatment, particularly for treatments other than opioid substitution. METHODS Data from closed drug and alcohol treatment episodes from the Alcohol and Other Drug Treatment Services National Minimum Data Set (AODTS-NMDS, representing non-opioid substitution treatment) in Australia for 2002-2003 to 2010-2011 were examined. In the four jurisdictions where detailed data were available, episodes where heroin was the principal drug of concern were compared to episodes for the four most frequently reported pharmaceutical opioids (morphine, codeine, fentanyl and oxycodone). RESULTS In 2002-2003, most (93%) opioid treatment was related to heroin with seven percent of all opioid treatment episodes reporting a PO as the principal drug of concern. In 2010-2011, 20% of all opioid treatment episodes were attributed to POs. Distinct changes over time were observed for different opioids. There was an increase in the average age at the start of treatment for heroin and oxycodone episodes, and a reduction in the proportion of females for codeine episodes, with 67% in 2002-2003 compared with 44% in 2010-2011. Codeine and oxycodone episodes had the lowest current or past injection rates. CONCLUSIONS Clear differences were observed over time and between different opioids. Monitoring these emerging patterns will be important to inform treatment needs, particularly in light of different patterns of poly drug use, different routes of administration and changing demographic characteristics.
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Affiliation(s)
- S Nielsen
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales 2052, Australia; Drug and Alcohol Services, South Eastern Sydney Local Health District, 591 South Dowling St, Surry Hills 2010, Australia.
| | - A Roxburgh
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales 2052, Australia
| | - R Bruno
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales 2052, Australia; School of Medicine, University of Tasmania, Level 1, Medical Science 1, 17 Liverpool Street, Hobart 7000, Australia
| | - N Lintzeris
- Drug and Alcohol Services, South Eastern Sydney Local Health District, 591 South Dowling St, Surry Hills 2010, Australia; University of Sydney, Department of Addiction Medicine, Missenden Road, Camperdown 2006, Australia
| | - A Jefferson
- Tobacco, Alcohol and Other Drugs Unit, Australian Institute of Health and Welfare, 1 Thynne Street, Fern Hill Park, Bruce 2617, Australia
| | - L Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales 2052, Australia
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Lintzeris N, Leung SY, Dunlop AJ, Larance B, White N, Rivas GR, Holland RM, Degenhardt L, Muhleisen P, Hurley M, Ali R. A randomised controlled trial of sublingual buprenorphine-naloxone film versus tablets in the management of opioid dependence. Drug Alcohol Depend 2013; 131:119-26. [PMID: 23317685 DOI: 10.1016/j.drugalcdep.2012.12.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 10/28/2012] [Accepted: 12/08/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Buprenorphine-naloxone sublingual film was introduced in 2011 in Australia as an alternative to tablets. This study compared the two formulations on subjective dose effects and equivalence, trough plasma levels, adverse events, patient satisfaction, supervised dosing time, and impact upon treatment outcomes (substance use, psychosocial function). METHODS 92 buprenorphine-naloxone tablet patients were recruited to this outpatient multi-site double-blind double-dummy parallel group trial. Patients were randomised to either tablets or film, without dose changes, over a 31 day period. RESULTS No significant group differences were observed for subjective dose effects, trough plasma buprenorphine or norbuprenorphine levels, adverse events and treatment outcomes. Buprenorphine-naloxone film took significantly less time to dissolve than tablets (173±71 versus 242±141s, p=0.007, F=7.67). CONCLUSIONS The study demonstrated dose equivalence and comparable clinical outcomes between the buprenorphine-naloxone film and tablet preparations, whilst showing improved dispensing times and patient ratings of satisfaction with the film.
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Affiliation(s)
- N Lintzeris
- Langton Centre, South Eastern Sydney Local Health District, NSW 2010, Australia.
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Abstract
Amphetamines are among the most widely used of illicit drugs in Australia, and evidence documenting the occurrence of amphetamine-related harms, particularly among chronic regular users, is increasing, A review of contemporary Australian treatment approaches suggests that conventional modalities are unlikely to address the needs of a large proportion of dependent amphetamine users. This has prompted clinicians in Australia and the United Kingdom to commence treatment programmes incorporating substitution therapy. Despite the positive impressions of clinicians involved in these programmes, further research is required to establish the role and efficacy of such treatment approaches. Issues to be addressed in the establishment of a controlled study are examined.
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Affiliation(s)
- N Lintzeris
- Turning Point Alcohol and Drug Centre, Fitzroy, Victoria, 3065, Australia
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Connock M, Juarez-Garcia A, Jowett S, Frew E, Liu Z, Taylor RJ, Fry-Smith A, Day E, Lintzeris N, Roberts T, Burls A, Taylor RS. Methadone and buprenorphine for the management of opioid dependence: a systematic review and economic evaluation. Health Technol Assess 2007; 11:1-171, iii-iv. [PMID: 17313907 DOI: 10.3310/hta11090] [Citation(s) in RCA: 282] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of buprenorphine maintenance therapy (BMT) and methadone maintenance therapy (MMT) for the management of opioid-dependent individuals. DATA SOURCES Major electronic databases were searched from inception to August 2005. Industry submissions to the National Institute for Health and Clinical Excellence were accessed. REVIEW METHODS The assessment of clinical effectiveness was based on a review of existing reviews plus an updated search for randomised controlled trials (RCTs). A decision tree with Monte Carlo simulation model was developed to assess the cost-effectiveness of BMT and MMT. Retention in treatment and opiate abuse parameters were sourced from the meta-analysis of RCTs directly comparing flexible MMT with flexible dose BMT. Utilities were derived from a panel representing a societal perspective. RESULTS Most of the included systematic reviews and RCTs were of moderate to good quality, and focused on short-term (up to 1-year follow-up) outcomes of retention in treatment and the level of opiate use (self-report or urinalysis). Most studies employed a trial design that compared a fixed-dose strategy (i.e. all individuals received a standard dose) of MMT or BMT and were conducted in predominantly young men who fulfilled criteria as opiate-dependent or heroin-dependent users, without significant co-morbidities. RCT meta-analyses have shown that a fixed dose of MMT or BMT has superior levels of retention in treatment and opiate use than placebo or no treatment, with higher fixed doses being more effective than lower fixed doses. There was evidence, primarily from non-randomised observational studies, that fixed-dose MMT reduces mortality, HIV risk behaviour and levels of crime compared with no therapy and one small RCT has shown the level of mortality with fixed-dose BMT to be significantly less than with placebo. Flexible dosing (i.e. individualised doses) of MMT and BMT is more reflective of real-world practice. Retention in treatment was superior for flexible MMT than flexible BMT dosing but there was no significant difference in opiate use. Indirect comparison of data from population cross-sectional studies suggests that mortality with BMT may be lower than that with MMT. A pooled RCT analysis showed no significant difference in serious adverse events with MMT compared with BMT. Although treatment modifier evidence was limited, adjunct psychosocial and contingency interventions (e.g. financial incentives for opiate-free urine samples) appeared to enhance the effects of both MMT and BMT. Also, MMT and BMT appear to be similarly effective whether delivered in a primary care or outpatient clinic setting. Although most of the included economic evaluations were considered to be of high quality, none used all of the appropriate parameters, effectiveness data, perspective and comparators required to make their results generalisable to the NHS context. One company (Schering-Plough) submitted cost-effectiveness evidence based on an economic model that had a 1-year time horizon and sourced data from a single RCT of flexible-dose MMT compared with flexible-dose BMT and utility values obtained from the literature; the results showed that for MMT vs no drug therapy, the incremental cost-effectiveness ratio (ICER) was pound 12,584/quality-adjusted life-year (QALY), for BMT versus no drug therapy, the ICER was pound 30,048/QALY and in a direct comparison, MMT was found to be slightly more effective and less costly than BMT. The assessment group model found for MMT versus no drug therapy that the ICER was pound 13,697/QALY, for BMT versus no drug therapy that the ICER was pound 26,429/QALY and, as with the industry model, in direct comparison, MMT was slightly more effective and less costly than BMT. When considering social costs, both MMT and BMT gave more health gain and were less costly than no drug treatment. These findings were robust to deterministic and probabilistic sensitivity analyses. CONCLUSIONS Both flexible-dose MMT and BMT are more clinically effective and more cost-effective than no drug therapy in dependent opiate users. In direct comparison, a flexible dosing strategy with MMT was found be somewhat more effective in maintaining individuals in treatment than flexible-dose BMT and therefore associated with a slightly higher health gain and lower costs. However, this needs to be balanced by the more recent experience of clinicians in the use of buprenorphine, the possible risk of higher mortality of MMT and individual opiate-dependent users' preferences. Future research should be directed towards the safety and effectiveness of MMT and BMT; potential safety concerns regarding methadone and buprenorphine, specifically mortality and key drug interactions; efficacy of substitution medications (in particular patient subgroups, such as within the criminal justice system, or within young people); and uncertainties in cost-effectiveness identified by current economic models.
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Affiliation(s)
- M Connock
- Department of Public Health and Epidemiology, University of Birmingham, UK
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Shanahan MD, Doran CM, Digiusto E, Bell J, Lintzeris N, White J, Ali R, Saunders JB, Mattick RP, Gilmour S. A cost-effectiveness analysis of heroin detoxification methods in the Australian National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD). Addict Behav 2006; 31:371-87. [PMID: 15972245 DOI: 10.1016/j.addbeh.2005.05.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2004] [Revised: 05/03/2005] [Accepted: 05/13/2005] [Indexed: 11/24/2022]
Abstract
This economic evaluation was part of the Australian National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD) project. Data from four trials of heroin detoxification methods, involving 365 participants, were pooled to enable a comprehensive comparison of the cost-effectiveness of five inpatient and outpatient detoxification methods. This study took the perspective of the treatment provider in assessing resource use and costs. Two short-term outcome measures were used-achievement of an initial 7-day period of abstinence, and entry into ongoing post-detoxification treatment. The mean costs of the various detoxification methods ranged widely, from AUD 491 dollars(buprenorphine-based outpatient); to AUD 605 dollars for conventional outpatient; AUD 1404 dollars for conventional inpatient; AUD 1990 dollars for rapid detoxification under sedation; and to AUD 2689 dollars for anaesthesia per episode. An incremental cost-effectiveness analysis was carried out using conventional outpatient detoxification as the base comparator. The buprenorphine-based outpatient detoxification method was found to be the most cost-effective method overall, and rapid opioid detoxification under sedation was the most cost-effective inpatient method.
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Affiliation(s)
- M D Shanahan
- National Drug and Alcohol Research Centre (NDARC), University of New South Wales, Sydney, NSW 2052, Australia.
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Paterson S, Lintzeris N, Mitchell TB, Cordero R, Nestor L, Strang J. Validation of techniques to detect illicit heroin use in patients prescribed pharmaceutical heroin for the management of opioid dependence. Addiction 2005; 100:1832-9. [PMID: 16367984 DOI: 10.1111/j.1360-0443.2005.01225.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The clinical implementation and evaluation of heroin substitution programmes have been confounded by the lack of objective and validated biomarkers for illicit heroin use in patients prescribed pharmaceutical heroin. This study examined the capacity to detect illicit heroin use by gas chromatography-mass spectrometry (GC-MS) analysis of urine samples for the presence of opium impurities common to illicit, but not pharmaceutical heroin. AIMS To characterize the diagnostic properties of the metabolites of noscapine and papaverine in comparison to morphine as a gold-standard marker of illicit heroin use; and to examine the relationships between the self-reported time since most recent heroin use and the detection of these opioids in urine. DESIGN A cross-sectional study of 52 opioid-dependent patients in treatment (not prescribed heroin), who self-reported illicit heroin use within the preceding 2 weeks. Self-report data regarding recent drug use and a urine sample were collected. GC-MS analyses of urines were conducted and reported by laboratory staff blinded to self-report data. FINDINGS The metabolites of papaverine (hydroxypapaverine and dihydroxypapeverine) were found to have high sensitivity, specificity and negative predictive values as markers for illicit heroin use compared to the 'gold-standard' morphine. Other opioids, including 6-mono-acetylmorphine (6-MAM), codeine and noscapine metabolites (e.g. meconine) were less adequate in detecting heroin use. CONCLUSIONS GC-MS detection of papaverine metabolites in urine appears to be suitable method of identifying illicit heroin use for clinical and research purposes.
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Affiliation(s)
- S Paterson
- Toxicology Unit, Imperial College London, UK
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16
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Abstract
BACKGROUND LAAM and methadone are both full mu opiate agonists and have been shown to reduce dependence on heroin when given continuously under supervised dosing conditions. LAAM has a long duration of action requiring dosing every two or three days compared to methadone which requires daily dosing. LAAM is not as widely available internationally as methadone, and may be withdrawn from the market following ten cases of life-threatening cardiac arrhythmias and an association with QT prolongation. OBJECTIVES To compare the efficacy and acceptability of LAAM maintenance with methadone maintenance in the treatment of heroin dependence. SEARCH STRATEGY We searched MEDLINE (January 1966 to August 2000), PsycINFO (1887 to August 2000), EMBASE (January 1985 to August 2000), and the Cochrane Controlled Trials Register (Issue 2 2000). In addition we hand searched NIDA monographs until August 2000 and searched reference lists of articles. SELECTION CRITERIA All randomised controlled trials, controlled clinical trials and controlled prospective studies comparing LAAM and methadone maintenance for the treatment of heroin dependence and measuring outcomes of efficacy or acceptability were included. DATA COLLECTION AND ANALYSIS Data on retention in treatment, heroin use, side-effects and mortality were collected by two reviewers independently. A meta-analysis was performed using RevMan. Discrepancies were resolved by consensus. MAIN RESULTS Eighteen studies, (15 RCTs, 3 Controlled prospective studies) met the inclusion criteria for the review. Three were excluded from the meta-analysis due to lack of data on retention, heroin use or mortality. Cessation of allocated medication (11 studies, 1473 participants) was greater with LAAM than with methadone, (RR 1.36, 95%CI 1.07-1.73, p=0.001, NNT=7.7 (or 8)). Non-abstinence was less with LAAM (5 studies, 983 participants; RR 0.81, 95%CI 0.72-0.91, p=0.0003, NNT=9.1 (or 10)). In 10 studies (1441 participants) there were 6 deaths from a range of causes, 5 in participants assigned to LAAM (RR 2.28 (95%CI 0.59-8.9, p=0.2). other relevant outcomes, such as quality of life and criminal activity could not be analysed because of lack of information in the primary studies. REVIEWER'S CONCLUSIONS LAAM appears more effective than methadone at reducing heroin use. More LAAM patients than methadone ceased their allocated medication during the studies, but many transferred to methadone and so the significance of this is unclear. There was no difference in safety observed, although there was not enough evidence to comment on uncommon adverse events.
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Affiliation(s)
- N Clark
- Turning Point Alcohol & Drug Centre, 54-62 Gertrude St, Fitzroy, Victoria, Australia, 3065.
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Lenné M, Lintzeris N, Breen C, Harris S, Hawken L, Mattick R, Ritter A. Withdrawal from methadone maintenance treatment: prognosis and participant perspectives. Aust N Z J Public Health 2001; 25:121-5. [PMID: 11357906 DOI: 10.1111/j.1753-6405.2001.tb01832.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To determine the proportion of clients engaged in methadone maintenance treatment who have favourable prognosis for withdrawal, and to examine client perceptions and expectations of withdrawal. METHODS A broad cross-section of 856 methadone clients was sampled across Melbourne, Sydney and Brisbane. Self-complete surveys were developed for the clients, their clinic staff or pharmacists, and methadone prescribers. The client survey examined aspects of the clients' perspectives of withdrawal, and the surveys for the service providers collected information about each client's current treatment episode. Informed consent was provided by clients to obtain information from their clinic staff member or pharmacist, and their methadone prescriber. RESULTS Most clients (70%) were at least very interested in methadone withdrawal. Clients were also more optimistic about their own post-withdrawal outcomes (in terms of opioid use) than both their clinic staff and prescribing doctors. Clinical criteria indicated that 31% of clients had a reasonable prognosis for withdrawal. However, when considering all factors, 17% had good withdrawal prognosis, were interested in methadone withdrawal, and believed it was very likely they would remain opioid-free for three months post-withdrawal. CONCLUSIONS Despite the likely continued increase in client numbers in substitution maintenance treatment, the majority of methadone clients have a poor prognosis for withdrawal and should not be encouraged to cease treatment. IMPLICATIONS Clients who do not meet key clinical criteria are likely to have poor clinical outcomes regardless of how withdrawal is attempted.
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Affiliation(s)
- M Lenné
- Turning Point Alcohol & Drug Centre Inc, Victoria.
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Berbatis CG, Sunderland VB, Bulsara M, Lintzeris N. Trends in licit opioid use in Australia, 1984-1998: comparative analysis of international and jurisdictional data. Med J Aust 2000; 173:524-7. [PMID: 11194735 DOI: 10.5694/j.1326-5377.2000.tb139320.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To examine trends from 1984 to 1998 in licit opioids used in Australia compared with nine other developed countries, and in New South Wales compared with other Australian jurisdictions. DESIGN Poisson regression analysis of annual rates of national and jurisdictional consumption of methadone, morphine and pethidine. MAIN OUTCOME MEASURES All drug data were standardised to defined daily doses per 1000 population per day. RESULTS Methadone consumption increased by, on average, 12% per year (RR, 1.12; 95% CI, 1.08-1.17), with Australia in the first rank of countries. Morphine use increased by 5% per year (RR, 1.05; 95% CI, 1.02-1.09), with Australia ranking equal second with three other countries behind Denmark. Consumption of pethidine in all 10 countries was unchanged (RR, 0.99; 95% CI, 0.97-1.00), with Australia equal first. In Australia, use of methadone syrup increased by 17% per year (RR, 1.17; 95% CI, 1.16-1.17) and by 11% per year for methadone tablets (RR, 1.11; 95% CI, 1.10-1.12). Consumption of methadone syrup in NSW was more than double that of any other jurisdiction. Consumption of methadone tablets was 2.4 times higher in South Australia (RR, 2.35; 95% CI, 2.09-2.65) than NSW. The Northern Territory, Tasmania and Queensland also had significantly higher consumption than NSW. From 1991 to 1998, controlled-release morphine consumption increased by 27% per year nationally (RR, 1.27; 95% CI, 1.24-1.30). The NT had 2.6 times more supply of morphine (RR, 2.63; 95% CI, 1.71-4.03) and Tasmania 58% more supply than NSW (RR, 1.58; 95% CI, 1.11-2.25). CONCLUSIONS Australia's consumption of licit opioids ranked high internationally. There were diverse trends in the supply of licit opioids to Australia's jurisdictions, resulting in a heterogeneous pattern throughout the country.
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Affiliation(s)
- C G Berbatis
- School of Pharmacy, Curtin University of Technology, Perth, WA.
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Abstract
AIMS The injection of methadone syrup designed for oral consumption is potentially associated with increased morbidity and mortality. Previous reports from Sydney, Australia have suggested a high prevalence of methadone injecting by clients in methadone programmes and by heroin users not in methadone treatment. This study sought to estimate the prevalence of methadone injecting by clients in community based methadone programmes in Melbourne, Australia, which operate under different take away policies. DESIGN The study used a cross-sectional survey of methadone clients using a self-complete questionnaire. Subjects were recruited from randomly selected methadone dispensing pharmacies across Melbourne. Participation was voluntary. PARTICIPANTS One hundred and sixty-eight methadone clients were recruited to the study. The mean age was 34.2 years; 59% were male. FINDINGS Two of 168 methadone clients reported having injected methadone within the preceding 6-month period. CONCLUSIONS The lower prevalence of methadone injecting in Melbourne (compared to Sydney) is thought to be due to the less liberal take-away policy, and the mandatory dilution of methadone take-aways to 200 ml of liquid. Implications for methadone take-away policies and procedures are discussed.
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Affiliation(s)
- N Lintzeris
- Turning Point Alcohol & Drug Centre Inc, Fitzroy, Victoria, Australia.
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