Methadone maintenance treatment and impulsivity: premature responding

INTRODUCTION

Previous research showed that methadone maintenance treatment (MMT) is linked to impulsivity, with higher impulsivity levels being associated with for example, increased drug use. One aspect of impulsivity, most commonly studied in rodent research, is premature responding, the failure to wait for a starting signal. Premature responding is of high translational significance since it predicts the development of addiction-like behaviors in rodents.

METHODS

We assessed 45 MMT patients and 46 demographically matched (age, sex, education, and handedness) healthy volunteers (HVs) on premature responding alongside action and inhibition of instructed and intentional trials using the Intentional Hand Task (IHT).

RESULTS

The results showed markedly enhanced premature responses in the MMT vs. the HV group, which correlated positively with methadone dosage in the MMT patients. Throughout the task, MMT patients were faster across all trial parts and less accurate in response to instructed trials compared to HVs.

CONCLUSIONS

The increase in premature motor reactions during variable waiting periods alongside increased motion speed and lower accuracy might reflect a specific motor inhibition deficit in MMT, a subcomponent of impulsivity not previously assessed in MMT. Incorporating an experimentally defined measure of impulsivity, such as premature responding, into existing test batteries used by clinicians might enable more tailored treatments addressing the increased impulsivity levels and associated dysfunctional behaviors in MMT.

Trends in Heroin Treatment Admissions in the United States by Race, Sex, and Age

This cross-sectional study examines trends in heroin treatment admission rates in the United States by race, sex, and age from 2000 to 2017.

Self-care habits among people who inject drugs with skin and soft tissue infections: a qualitative analysis

BACKGROUND

Injection drug use is on the rise in the USA, and skin and soft tissue infections (SSTI) are a common complication, resulting in significant morbidity and mortality. Due to structural barriers to care-seeking, many people who inject drugs avoid formal care and resort to self-care techniques, but little is known about the nature of these techniques, or more generally about the accuracy or breadth of this population's knowledge of SSTIs.

METHODS

Semi-structured qualitative interviews were conducted with 12 people who inject heroin in two metropolitan areas: Sacramento and Boston, USA.

RESULTS

These interviews reveal a robust and accurate knowledge base regarding skin infections, including the progression from simple cellulitis to an abscess, and acknowledgment of the possibility of serious infections. Nonetheless, there remains a reticence to seek care secondary to past traumatic experiences. A step-wise approach to self-care of SSTI infections was identified, which included themes of whole-body health, topical applications, use of non-prescribed antibiotics, and incision and drainage by non-medical providers.

CONCLUSIONS

The reported SSTI self-care strategies demonstrate resilience and ingenuity, but also raise serious concerns about inappropriate antibiotic consumption and complications of invasive surgical procedures performed without proper training, technique, or materials. Harm reduction agencies and health care providers should work to obviate the need for these potentially dangerous practices by improving healthcare access for this population. In the absence of robust solutions to meet the needs of this population, education materials should be developed to optimize the efficacy and minimize the harms of these practices, while empowering and supporting the autonomy of people who use drugs and providing clear guidance on when self-care should be abandoned in favor of formal medical care.

In their own words: language preferences of individuals who use heroin

BACKGROUND AND AIMS

Use of non-judgmental, respectful and uniform language to describe individuals with substance use disorders (SUD) is recommended to reduce stigma. However, existing research concerning the use of labels for substance use has largely focused on perspectives of treatment providers and the general public, and to a lesser degree of those in long-term recovery. This study aimed to examine and compare labels that individuals who use heroin and are initiating SUD treatment (1) use to describe themselves and when speaking with others who use drugs, with family and with treatment providers, and (2) prefer to be called and never want to be called. Design and Setting This was a cross-sectional survey study using a convenience sample of individuals initiating an in-patient managed withdrawal program in Massachusetts, USA.

PARTICIPANTS

Between October 2017 and May 2018, 263 participants were enrolled.

MEASURES

Participants completed a survey about (1) what labels they used to refer to self and when talking with others who use drugs, with providers, families and at 12-Step meetings and (2) to identify which label they preferred least and most for others to use when referring to them.

FINDINGS

More than 70% of participants used the term 'addict' to describe themselves and when speaking with others. However, use of 'addict' varied by context, and was most common at 12-Step programs. Fewer than 15% reported using 'user' or slang terms, most commonly 'junkie', in any communications. The most-preferred label for others to call them was 'person who uses drugs', while the most common label that participants never wanted to be called was 'heroin misuser' or 'heroin-dependent'.

CONCLUSION

Label preferences by individuals who use heroin and are in early recovery are consistent with general guidelines about use of first-person language and suggest avoidance of language indicative of drug misuse or dependence.

Profiles of visuospatial memory dysfunction in opioid-exposed and dependent populations

BACKGROUND

Chronic opioid exposure is common world-wide, but behavioural performance remains under-investigated. This study aimed to investigate visuospatial memory performance in opioid-exposed and dependent clinical populations and its associations with measures of intelligence and cognitive impulsivity.

METHODS

We recruited 109 participants: (i) patients with a history of opioid dependence due to chronic heroin use (n = 24), (ii) heroin users stabilised on methadone maintenance treatment (n = 29), (iii) participants with a history of chronic pain and prescribed tramadol and codeine (n = 28) and (iv) healthy controls (n = 28). The neuropsychological tasks from the Cambridge Neuropsychological Test Automated Battery included the Delayed Matching to Sample (DMS), Pattern Recognition Memory, Spatial Recognition Memory, Paired Associate Learning, Spatial Span Task, Spatial Working Memory and Cambridge Gambling Task. Pre-morbid general intelligence was assessed using the National Adult Reading Test.

RESULTS

As hypothesised, this study identified the differential effects of chronic heroin and methadone exposures on neuropsychological measures of visuospatial memory (p < 0.01) that were independent of injecting behaviour and dependence status. The study also identified an improvement in DMS performance (specifically at longer delays) when the methadone group was compared with the heroin group and also when the heroin group was stabilised onto methadone. Results identified differential effects of chronic heroin and methadone exposures on various neuropsychological measures of visuospatial memory independently from addiction severity measures, such as injecting behaviour and dependence status.

Facing the Growing Heroin Problem in Colombia: The New Methadone-assisted Treatment Programs

OBJECTIVE

Colombia is facing a rising epidemic of intravenous heroin use. Knowledge of the methadone-assisted treatment programs in the country is crucial in order to propose improvement strategies.

METHODS

13 programmes from priority regions were surveyed. The demographic and clinical characteristics of the patients attending the programs, a description of the services offered, their methadone treatment protocols, the various barriers to treatment and the causes of treatment abandonment were reviewed.

RESULTS

12/13 questionnaires were analysed with a total of 538 active patients. Most of the patients attending these programs were men (85.5%) between 18 and 34 years-old (70%). Forty percent (40%) were intravenous drug users and 25% admitted sharing needles. The comorbidities associated with heroin use were mental illness (48%), hepatitis C (8.7%) and HIV (2%). Psychiatric comorbidity was more likely in patients attending the private sector (69.8% vs 29.7%; p<0.03). The initial average dose of methadone administered was 25.3±8.9mg/day, with a maintenance dose ranging from 41 to 80mg/day. Lack of alignment with primary care was perceived to be the most serious barrier to access, ahead of problems with insurance and prejudice towards treatment with methadone (p<0.05). Health Administration and insurance problems (p<0.003), together with the lack of availability of methadone (p<0.018) and relapse (p<0.014) were the most important reasons for abandonment of treatment.

CONCLUSIONS

The treatment protocols of these programmes offer different levels of development and implementation. Some of the barriers to access and reasons for abandonment of treatment with methadone can be mitigated with better health administration.

Increased use of heroin as an initiating opioid of abuse: Further considerations and policy implications

INTRODUCTION

Previously, we reported a marked increase in the use of heroin as an initiating opioid in non-tolerant, first time opioid users. In the current paper, we sought to update and expand upon these results, with a discussion of the policy implications on the overall opioid epidemic.

METHODS

Opioid initiation data from the original study were updated to include surveys completed through 2017 (N = 8382) from a national sample of treatment-seeking opioid users. In addition, past month abuse of heroin and prescription were analyzed as raw numbers of treatment program entrant in the last five years (2013-2017), drawing from only those treatment centers that participated every year in that time frame.

RESULTS

The updated data confirm and extend the results of our original study: the use of heroin as an initiating opioid increased from 8.7% in 2005 to 31.6% in 2015, with increases in overall Ns per initiation year reflecting a narrowing of the "treatment gap", the time lag between opioid initiation from 2005 to 2015 and later treatment admission (up to 2017). Slight decreases were observed in treatment admissions, but this decline was totally confined to prescription opioid use, with heroin use continuing to increase in absolute numbers.

CONCLUSIONS

Given that opioid novices have limited tolerance, the risk of fatal overdose for heroin initiates is elevated compared to prescription opioids, particularly given non-oral administration and often unknown purity/adulterants (i.e., fentanyl). Imprecision of titrating dose among opioid novices may explain observed increases opioid overdoses. Future policy decisions should note that prescription opioid-specific interventions may have little impact on a growing heroin epidemic.

U.S. adults with opioid use disorder living with children: Treatment use and barriers to care

BACKGROUND

U.S. Adults with an opioid use disorder who live with a child have unique treatment needs, but little is known about the treatment use of these adults.

METHODS

Data come from the 2010-2014 versions of the National Survey on Drug Use and Health, an annual, nationally representative survey assessing substance use in the United States. Adults (>18) with a heroin or pain-reliever use disorder living in a household with a child (<18) were compared to adults not living with children on their use of substance use treatment, treatment settings, payment sources, perceived unmet need for treatment, and barriers to care using logistic regression to adjust for demographic differences between groups.

RESULTS

Of the 820,000 adults with an opioid use disorder living with at least one child, 28% reported receiving any past-year substance use treatment, a rate comparable to adults not living with a child (30%). Among adults reporting unmet treatment need, those who lived with a child were more likely to report that access barriers like not being able to find the right kind of program (aOR 2.9, 95% CI 1.2-7.1), as well as stigma (aOR 4.1, 95% CI 1.5 to 11.2), kept them from receiving care.

CONCLUSION

Most adults with opioid use disorder who live with a child are not receiving any substance use treatment. Efforts to expand opioid use disorder treatment programs must include investment in programs that meet the specialized needs of families.

Factors associated with methadone maintenance therapy discontinuation among people who inject drugs

BACKGROUND

Methadone maintenance therapy (MMT) continues to be a key treatment for opioid use disorder, although premature discontinuation of MMT can increase risk for overdose and other severe harms. We examined sociodemographic characteristics, substance use patterns and social-structural exposures associated with MMT discontinuation among a cohort of people who use drugs (PWUD) in Vancouver, Canada.

METHODS

Data were derived from VIDUS and ACCESS, prospective cohorts of PWUD in Vancouver, Canada. The outcome of interest was self-reported discontinuation of MMT within the last six months. Multivariable Generalized Estimating Equations (GEE) were conducted to identify factors independently associated with MMT discontinuation.

RESULTS

Between 2005 and 2015, 1301 PWUD who had accessed MMT were recruited, among whom 288 (22.1%) discontinued MMT at least once during the study period. In multivariable GEE analyses, homelessness (Adjusted Odds Ratio [AOR] = 1.46, 95% Confidence Interval [95% CI]: 1.09-1.95), daily heroin injection (AOR = 5.17, 95% CI: 3.82-6.99), daily prescription opioid use (injection or non-injection) (AOR = 2.18, 95% CI: 1.30-3.67), recent incarceration (AOR = 1.46, 95% CI: 1.01-2.12), and not being on any form of income assistance (AOR = 2.14, 95% CI: 1.33-3.46) were each independently positively associated with MMT discontinuation. Participants with more study visits on methadone (>50% vs. ≤50% of visits) (AOR = 0.63, 95% CI: 0.47-0.85) and those with higher methadone dose (>100 mg vs. <60 mg per day) (AOR = 0.44, 95% CI: 0.31-0.62) were less likely to discontinue MMT.

DISCUSSION AND CONCLUSIONS

Discontinuation of MMT in this urban setting was associated with recent homelessness and incarceration, not accessing social income assistance, as well as daily prescription opioid use and daily heroin injection drug use. These findings underscore a need to reduce potential barriers to MMT retention by providing access to stable housing and preventing treatment interruptions during transitions between community and custodial settings.

Idling in Mao's Shadow: Heroin Addiction and the Contested Therapeutic Value of Socialist Traditions of Laboring

The Chinese government has come under attack by international critics for forcing drug users to labor in the name of treatment. While joining these activists in criticizing conditions in compulsory labor centers, former detainees who congregated at a drop-in center in southern Yunnan also defended the therapeutic potential of socialist legacies of laboring. Shuttling between laboring in state compulsory centers and idling in a market economy, long-term heroin users saw their difficulties in recovering from addiction as inextricably linked to their inability to find suitable work opportunities. Certain drop-in center attendees maintained that earlier Communist laboring projects had helped wayward citizens, including drug addicts, "merge into" society as productive workers. This group evoked the stable long-term jobs and benefits once provided by local state-owned enterprises and the radical revolutionary power of "remolding through labor" they imagined to have existed in the first years of the People's Republic as powerful alternatives to their recent crisis of idling. The nuanced ways that drop-in center regulars revisited the potential healing power of earlier traditions of socialist laboring as remedies to their contemporary struggles complicates long-standing debates about coercion in treatment and the responsibility of the postsocialist state towards marginalized workers.

Polydrug use and its association with drug treatment outcomes among primary heroin, methamphetamine, and cocaine users

BACKGROUND

Polydrug use may challenge effective treatment for substance use disorders. We evaluate whether secondary substance use modifies the association between treatment and primary drug use among primary heroin, cocaine and methamphetamine (MA) users.

METHODS

Data were obtained from prospective cohort studies on people who use illicit drugs (PWUD) in California, USA. Using repeated monthly data on self-reported secondary substance use (heroin, cocaine, MA, alcohol or marijuana; ≥1day in a month), primary drug use (≥1day in a month), and treatment participation, collected via timeline follow-back, we fitted generalized linear mixed multiple regression models controlling for potential confounders to examine the interactions between treatment and secondary substance use on the odds of primary heroin, cocaine and MA use, respectively.

RESULTS

Included in our study were 587 primary heroin, 444 primary MA, and 501 primary cocaine users, with a median of 32.4, 13.3 and 18.9 years of follow-up, respectively. In the absence of secondary substance use, treatment was strongly associated with decreased odds of primary drug use (adjusted odds ratios (aORs): 0.25, 95% CI: 0.24, 0.27, 0.07 (0.06, 0.08), and 0.07 (0.07, 0.09)) for primary heroin, MA, and cocaine users, respectively. Secondary substance use of any kind moderated these associations (0.82 (0.78, 0.87), 0.25 (0.21, 0.30) and 0.53 (0.45, 0.61), respectively), and these findings were consistent for each type of secondary substance considered. Moreover, we observed different associations in terms of direction and magnitude between secondary substance use and primary drug use during off-treatment periods across substance types.

CONCLUSION

This study demonstrates secondary substance use moderates the temporal associations between treatment and primary drug use among primary heroin, MA and cocaine users. Disparate patterns of polydrug use require careful measurement and analysis to inform targeted treatment for polydrug users.

Heroin refusal self-efficacy and preference for medication-assisted treatment after inpatient detoxification

OBJECTIVE

An individual's self-efficacy to refuse using heroin in high-risk situations is believed to minimize the likelihood for relapse. However, among individuals completing inpatient heroin detoxification, perceived refusal self-efficacy may also reduce one's perceived need for medication-assisted treatment (MAT), an effective and recommended treatment for opioid use disorder. In the current study, we examined the relationship between heroin refusal self-efficacy and preference for MAT following inpatient detoxification.

METHOD

Participants (N=397) were interviewed at the start of brief inpatient opioid detoxification. Multiple logistic regression was used to estimate the adjusted association of background characteristics, depressed mood, and perceived heroin refusal self-efficacy with preference for MAT.

RESULTS

Controlling for other covariates, depressed mood and lower perceived refusal self-efficacy were associated with a significantly greater likelihood of expressing preference for MAT (versus no MAT).

CONCLUSIONS

Perceived ability to refuse heroin after leaving detox is inversely associated with a heroin user's desire for MAT. An effective continuum of care model may benefit from greater attention to patient's perceived refusal self-efficacy during detoxification which may impact preference for MAT and long-term recovery.

The Role of Behavioral Interventions in Buprenorphine Maintenance Treatment: A Review

OBJECTIVE

Although counseling is a required part of office-based buprenorphine treatment of opioid use disorders, the nature of what constitutes appropriate counseling is unclear and controversial. The authors review the literature on the role, nature, and intensity of behavioral interventions in office-based buprenorphine treatment.

METHOD

The authors conducted a review of randomized controlled studies testing the efficacy of adding a behavioral intervention to buprenorphine maintenance treatment.

RESULTS

Four key studies showed no benefit from adding a behavioral intervention to buprenorphine plus medical management, and four studies indicated some benefit for specific behavioral interventions, primarily contingency management. The authors examined the findings from the negative trials in the context of six questions: 1) Is buprenorphine that effective? 2) Is medical management that effective? 3) Are behavioral interventions that ineffective in this population? 4) How has research design affected the results of studies of buprenorphine plus behavioral treatment? 5) What do we know about subgroups of patients who do and those who do not seem to benefit from behavioral interventions? 6) What should clinicians aim for in terms of treatment outcome in buprenorphine maintenance?

CONCLUSIONS

High-quality medical management may suffice for some patients, but there are few data regarding the types of individuals for whom medical management is sufficient. Physicians should consider a stepped-care model in which patients may begin with relatively nonintensive treatment, with increased intensity for patients who struggle early in treatment. Finally, with 6-month retention rates seldom exceeding 50% and poor outcomes following dropout, we must explore innovative strategies for enhancing retention in buprenorphine treatment.

An Examination of Women Ex-Offenders With Methadone Histories

Criminal (drug and prostitution) charges, employment levels (weekly hours), recent substance use in the past 6 months, and primary sources of income were examined among a sample ( n = 106) of women ex-offenders who had opioid use disorders with and without methadone histories. A general linear model was tested to examine differences in relation to methadone use history. Results from a one-way MANCOVA found that those with methadone histories reported significantly higher levels of drug and prostitution charges than those without any methadone history, but no significant differences in terms of weekly hours of employment or recent substance use were observed between groups. Women ex-offenders with methadone histories reported various sources of income beyond employment, and proportionally, more of these women reported prostitution as a primary source of income. Findings suggest that methadone maintenance treatments are not sufficient in meeting the needs of women ex-offenders.

Medical Narrative and the Rhetoric of Identification: The Many Faces of Anna White Dildane

When Anna White Dildane, a prostitute and heroin addict, was committed to the Laboratory of Social Hygiene (LSH) in 1917, she was treated by a staff that anticipated the methods of the biopsychosocial model later developed by Engel. That is to say, the staff members believed that Anna's rehabilitation was contingent on a scientific diagnosis of the physical, mental, and social factors that underlay her condition. However, using Anna and the LSH as a case study, we draw from Latour to show the limitations of this "modern" method of diagnosis and treatment that persists today. Using Burke, we advocate for a pragmatic orientation focused on creating rhetorically oriented narratives whose aim is to help patients make judgments about their health and future, namely, by bringing about the experience of "form" capable of constituting new types of identification. Effective medical rhetoric thus adopts a method of persuasion that begins with the narrative and self-understanding of the patient, links aspects of that narrative with the technical expertise of physicians and other health care providers, and crafts a new, more specialized narrative attentive to the desires and constraints of a patient's form of identification that is ultimately the seat of judgment.

Risk-factors for methadone-specific deaths in Scotland's methadone-prescription clients between 2009 and 2013

AIM

To quantify gender, age-group and quantity of methadone prescribed as risk factors for drugs-related deaths (DRDs), and for methadone-specific DRDs, in Scotland's methadone-prescription clients.

DESIGN

Linkage to death-records for Scotland's methadone-clients with one or more Community Health Index (CHI)-identified methadone prescriptions during July 2009 to June 2013.

SETTING

Scotland's Prescribing Information System and National Records of Scotland.

MEASUREMENTS

Covariates defined at first CHI-identified methadone prescription, and person-years at-risk (pys) thereafter until the earlier of death-date or 31 December 2013. Methadone-specific DRDs were defined as: methadone implicated but neither heroin nor buprenorphine. Hazard ratios (HRs) were assessed using proportional hazards regression.

FINDINGS

Scotland's CHI-identified methadone-prescription cohort comprised 33,128 clients, 121,254 pys, 1,171 non-DRDs and 760 DRDs (6.3 per 1,000 pys), of which 362 were methadone-specific. Irrespective of gender, methadone-specific DRD-rate, per 1,000 pys, was higher in the 35+ age-group (4.2; 95% CI: 3.6-4.7) than for younger clients (1.9; 95% CI: 1.5-2.2). For methadone-specific DRDs, age-related HRs (e.g., 2.9 at 45+ years; 95% CI: 2.1-3.9) were steeper than for all DRDs (1.9; 95% CI: 1.5-2.4); there was no hazard-reduction for females; no gender by age-group interaction; and, unlike for all DRDs, the highest quintile for quantity of prescribed methadone at cohort-entry (>1960mg) was associated with increased HR (1.8; 95% CI: 1.3-2.5).

CONCLUSION

Higher methadone-specific DRD rates in older clients, irrespective of gender, call for better understanding of methadone's pharmaco-dynamics in older, opioid-dependent clients, many with progressive physical or mental ill-health.

Abnormal interhemispheric resting state functional connectivity of the insula in heroin users under methadone maintenance treatment

Abnormal interhemispheric functional connectivity is attracting more and more attention in the field of substance use. This study aimed to examine 1) the differences in interhemispheric functional connections of the insula with the contralateral insula and other brain regions between heroin users under methadone maintenance treatment (MMT) and healthy controls, and 2) the association between heroin users' interhemispheric insular functional connectivity using resting functional magnetic resonance imaging (fMRI) and the results of urine heroin analysis. Sixty male right-handed persons, including 30 with heroin dependence under MMT and 30 healthy controls, were recruited to this study. Resting fMRI experiments and urine heroin analysis were performed. Compared with the controls, the heroin users had a significantly lower interhemispheric insular functional connectivity. They also exhibited lower functional connectivity between insula and contralateral inferior orbital frontal lobe. After controlling for age, educational level and methadone dosage, less deviation of the interhemispheric insula functional connectivity was significantly associated with a lower risk of a positive urine heroin analysis result. Our findings demonstrated that the heroin users under MMT had abnormal long-range and interhemispheric resting functional connections. Those with a less dysfunctional interhemispheric insula functional connectivity had a lower risk of a positive urine heroin test.

Development and Initial Examination of a Brief Intervention for Heightened Anxiety Sensitivity Among Heroin Users

Anxiety sensitivity (AS) recently has been identified as a potential cognitive vulnerability underlying substance use problems, with some evidence specifically indicating its relevance to heroin. Focusing on the potential utility of interventions centered on increasing willingness to have anxiety-related sensations reduce vulnerability for relapse following substance use treatment, the current article describes the development of a brief (6 session) behavioral treatment for heightened AS among heroin users. The treatment consists of the following components: (a) psychoeducation about anxiety; (b) interoceptive exposure exercises; and (c) skills-training focused on heightening emotional acceptance, tolerance, and nonevaluative awareness (to facilitate willingness). Preliminary data on this treatment are provided in the form of a case study with a 46-year-old African American man in an inner-city residential substance use treatment facility. Results indicate reductions in AS (especially physical concerns), as well as corresponding decreases in heroin cravings and improvements in emotion regulation.

Effectiveness of Methadone Maintenance Therapy and Improvement in Quality of Life Following a Decade of Implementation

Methadone maintenance therapy has been found to be an effective harm reduction treatment for opioid use disorder. However evidence of its benefits over a longer duration of treatment is limited as most studies focus on its short term benefits. As methadone maintenance therapy reaches a decade since its implementation in Malaysia, this study sought to examine the effectiveness of methadone treatment, change in quality of life among patients since entry to methadone treatment, as well as factors predicting the magnitude of change in quality of life. This study found that methadone maintenance therapy was effective in reducing heroin use, injecting practices and crime, and in improving in social functioning and physical symptoms, but not in reducing sex-related HIV risk-taking behavior. Though patients had a significantly better quality of life at follow-up than at entry to methadone maintenance therapy, the improvement in quality of life was not significantly greater as the duration of treatment increased. Age above 50 years old, human immunodeficiency virus (HIV) positive status and physical symptoms predicted a poorer improvement in quality of life between baseline and follow-up. On the other hand, patients with hepatitis B showed a greater improvement in quality of life in the social relationships domain compared to patients without hepatitis B. In conclusion, methadone maintenance therapy is an effective treatment for opioid use disorder and improves quality of life but its benefits in further improving quality of life beyond a decade of treatment need further evaluation.

Sustained-release dexamfetamine in the treatment of chronic cocaine-dependent patients on heroin-assisted treatment: a randomised, double-blind, placebo-controlled trial

BACKGROUND

Heroin-assisted treatment is effective for methadone treatment-refractory heroin-dependent patients, but continued comorbid cocaine dependence remains problematic. Sustained-release dexamfetamine is a promising agonist pharmacotherapy for cocaine dependence and we aimed to assess its acceptance, efficacy, and safety.

METHODS

In this multicentre, randomised, double-blind, placebo-controlled trial, patients who were treatment-refractory, as indicated by at least two earlier failed treatments aimed at reducing or abstaining from cocaine use, and who regularly (≥8 days/month) used crack-cocaine were enrolled from four heroin-assisted treatment centres in the Netherlands. Eligible patients were randomly assigned (1:1) to receive either 12 weeks of daily, supervised prescription of 60 mg/day oral sustained-release dexamfetamine or placebo in addition to co-prescribed methadone and diacetylmorphine. Randomisation was done by the collaborating pharmacist, using a computer-generated random number sequence with stratification by treatment centre in blocks of four per stratum. Randomisation was masked to patients, staff, and researchers throughout the study. The primary outcome was the number of self-reported days of cocaine use during study treatment, assessed every 4 weeks. Primary and safety analyses were done in the intention-to-treat population. The study was registered with the European Union Drug Regulating Authorities Clinical Trials (EUdraCT 2013-004024-11) and with The Netherlands Trial Register (NTR2576).

FINDINGS

Between Aug 8, 2014, and Feb 27, 2015, 111 patients were assessed for eligibility, of whom 73 were enrolled and randomised; 38 patients were assigned to the sustained-release dexamfetamine group and 35 to the placebo group. Sustained-release dexamfetamine treatment resulted in significantly fewer days of cocaine use than placebo treatment (mean 44·9 days [SD 29·4] vs 60·6 days [24·3], respectively [95% CI of difference 3·1-28·4]; p=0·031; Cohen's standardised effect size d=0·58). One or more adverse events were reported by 28 (74%) patients in the dexamfetamine group and by 16 (46%) patients in the placebo group. Most adverse events were transient and well-tolerated.

INTERPRETATION

Sustained-release dexamfetamine is a well accepted, effective, and safe agonist pharmacotherapy for comorbid treatment-refractory cocaine dependence in heroin-dependent patients in heroin-assisted treatment. Future research should aim to replicate these findings in chronic cocaine-dependent and other stimulant-dependent patients in more routine treatment settings, including strategies to optimise treatment adherence like medication management interventions and contingency management.

FUNDING

Netherlands Organisation for Health Research and Development.

Factors Associated with Relapse among Heroin Addicts: Evidence from a Two-Year Community-Based Follow-Up Study in China

Background: Many countries including China are facing a serious opiate dependence problem. Anti-drug work effectiveness was affected by the high relapse rate all over the world. This study aims to analyze the factors influencing heroin addict relapse, and to provide evidence for generating relapse prevention strategies. Methods: A community-based follow-up study was conducted in China between October 2010 and September 2012. A total of 554 heroin addicts in accordance with the inclusion criteria from 81 streets in 12 districts of Shanghai, China were divided into 4 groups: group 1—daily dosage taken orally of 60 mL of methadone or under combined with psychological counseling and social supports (n = 130); group 2—daily dosage taken orally of over 60 mL of methadone combined with psychological counseling and social supports (n = 50); group 3—JTT (Jitai tablets) combined with psychological counseling and social supports (n = 206); group 4—JTT combined with social supports (n = 168). Results: Log-rank test results showed that the cumulative relapse rate differences among four groups during the two-year follow-up period were not statistically significant (χ² = 5.889, p = 0.117). Multivariate Cox regression analysis results showed that only three independent variables were still statistically significant, including compliance with participation in psychological counseling (OR = 3.563, p = 0.000), the years of drug use (OR = 1.078, p = 0.001)and intervention model. Conclusions: Using the detoxification medications combined with appropriate psychological counseling and social support measures will help improve the effectiveness of relapse prevention, which is a kind of alternative community detoxification pattern. Appropriate and standard psychological counseling is very important for anti-drug treatment. The longer the drug addiction lasts, the longer the anti-drug treatment takes.

Adolescents at risk: pain pills to heroin: part II

Casually exposing adolescents to prescription opioid agents may escalate to daily use. A trend exists for adolescents using prescription opioid agents to substitute heroin because it is significantly cheaper than pills (approximately half of the cost) and is often more readily available. Additionally, it is more potent than most prescription opioid agents and carries increased risks of overdose and death. Although treatment for substance use disorders has traditionally centered on total abstinence, opioid replacement therapy (ORT) is an option that saves lives and prevents overdose deaths. In the United States, ORT is based on two medicines: methadone and buprenorphine. These drugs can be substituted for other opiate agents and have much lower overdose risks. Nursing implications and web-based resources for teaching are presented.

AN OVERVIEW OF THE EFFICACY OF THE 12-STEP GROUP THERAPY FOR SUBSTANCE ABUSE TREATMENT

This study was designed to determine if 12-Steps groups efficacy for substance abuse treatment significantly improve abstinence rates of heroin addicts in the short run and long run (1-year and 5-year period); and if abstinence rates are found to be lower for heroin addicts that have attended 12-Step groups at the 1-year mark, and if similar results would be expected at the 5-year mark. Secondary data from the Inter-University Consortium of Political and Social Research (ICPSR) was extracted and analyzed for the aforementioned hypothesis. Using SSPS to test the research hypothesis for the 1-Year Follow Up, the chi-square test shows a p-value below of .10, and the analysis determined that there was significant evidence to support the hypothesis that cases in a 12-Steps or self-help program have a higher success than cases not in a program for the 1-year follow up. For 5-Year Follow Up, the cases that attended a 12-Step program or a self-help program and about 27% went on to use heroin during the last 12 months compared to 34% cases that did not go to a program.

Understanding Heroin Overdose: A Study of the Acute Respiratory Depressant Effects of Injected Pharmaceutical Heroin

Opioids are respiratory depressants and heroin/opioid overdose is a major contributor to the excess mortality of heroin addicts. The individual and situational variability of respiratory depression caused by intravenous heroin is poorly understood. This study used advanced respiratory monitoring to follow the time course and severity of acute opioid-induced respiratory depression. 10 patients (9/10 with chronic airflow obstruction) undergoing supervised injectable opioid treatment for heroin addiction received their usual prescribed dose of injectable opioid (diamorphine or methadone) (IOT), and their usual prescribed dose of oral opioid (methadone or sustained release oral morphine) after 30 minutes. The main outcome measures were pulse oximetry (SpO2%), end-tidal CO2% (ETCO2%) and neural respiratory drive (NRD) (quantified using parasternal intercostal muscle electromyography). Significant respiratory depression was defined as absence of inspiratory airflow >10s, SpO2% < 90% for >10s and ETCO2% per breath >6.5%. Increases in ETCO2% indicated significant respiratory depression following IOT in 8/10 patients at 30 minutes. In contrast, SpO2% indicated significant respiratory depression in only 4/10 patients, with small absolute changes in SpO2% at 30 minutes. A decline in NRD from baseline to 30 minutes post IOT was also observed, but was not statistically significant. Baseline NRD and opioid-induced drop in SpO2% were inversely related. We conclude that significant acute respiratory depression is commonly induced by opioid drugs prescribed to treat opioid addiction. Hypoventilation is reliably detected by capnography, but not by SpO2% alone. Chronic suppression of NRD in the presence of underlying lung disease may be a risk factor for acute opioid-induced respiratory depression.

Methadone Maintenance Therapy and the Dental Patient

Methadone is a Schedule II drug best known for its use in the treatment of opioid dependence. Dental providers should be aware of the oral and systemic effects of methadone. In patients undergoing methadone maintenance therapy, there is a higher incidence of rampant caries, xerostomia, bruxism and poor oral hygiene. A review of the pharmacology, systemic effects, drug interactions and oral manifestations is presented, as well as possible modifications to treatment and specific considerations in dental therapies.

Short-term cessation of sex work and injection drug use: evidence from a recurrent event survival analysis

OBJECTIVE

This study quantitatively examined the prevalence and correlates of short-term sex work cessation among female sex workers who inject drugs (FSW-IDUs) and determined whether injection drug use was independently associated with cessation.

METHODS

We used data from FSW-IDUs (n=467) enrolled into an intervention designed to increase condom use and decrease sharing of injection equipment but was not designed to promote sex work cessation. We applied a survival analysis that accounted for quit-re-entry patterns of sex work over 1-year stratified by city, Tijuana and Ciudad Juarez, Mexico.

RESULTS

Overall, 55% of participants stopped sex work at least once during follow-up. Controlling for other characteristics and intervention assignment, injection drug use was inversely associated with short-term sex work cessation in both cities. In Ciudad Juarez, women receiving drug treatment during follow-up had a 2-fold increase in the hazard of stopping sex work. In both cities, income from sources other than sex work, police interactions and healthcare access were independently and significantly associated with shorter-term cessation.

CONCLUSIONS

Short-term sex work cessation was significantly affected by injection drug use. Expanded drug treatment and counseling coupled with supportive services such as relapse prevention, job training, and provision of alternate employment opportunities may promote longer-term cessation among women motivated to leave the sex industry.

Health service utilization of heroin abusers: a retrospective cohort study

AIMS

This study aimed to determine the patterns of medical service utilization among heroin users and to identify the factors associated with the frequency of utilization.

METHODS

We conducted a retrospective/prospective cohort study of 789 heroin-using adults in a catchment area, collecting data on their usage of medical care, including inpatient care, emergency visits, and outpatient care, in a 2-year observation period. We interviewed and reviewed the medical records of 789 heroin users in a methadone clinic of a general hospital in a rural area of Taiwan. The demographic data, records of service use, diagnoses, and information on viral infection status from Jan. 1, 2007 to Dec. 31, 2008 were collected. Most patients were middle-aged and unemployed, had a basic educational level, and began their first heroin use in their twenties.

RESULTS

The health service utilization of heroin users was mostly for infectious diseases, orthopedic conditions, and gastroenterological disorders mainly due to blood-borne or local infections and traumatic injury. Heroin users utilize fewer outpatient or inpatient services, but more emergency care than the general public. The major correlates of inpatient and emergency service utilization were HIV status and education level.

CONCLUSIONS

Our findings suggest that integrated outpatient services may help to enhance medical service accessibility and adherence, and also imply the necessity of putting more effort into promoting health management and safe behaviors in heroin users, particularly the lower-educated addicts.

Familial expressed emotion among heroin addicts in methadone maintenance treatment: does it matter?

BACKGROUND

Expressed emotion (EE) is the quality of the atmosphere between a relative and a family member with mental illness. Substantial research has focused on the relationship between the level of EE and the outcomes of mental illness. However, no prior study has explored the role of EE relative to heroin addicts.

AIM

The aims of this study were to investigate the influence of EE on patient outcome in methadone maintenance treatment (MMT) and the relationship between the EE of heroin addicts and other demographic and psychological variables.

METHODS

A total of 117 heroin addicts who entered MMT were enrolled. Each subject underwent a comprehensive interview to record demographic data and drug use history. The Family Emotional Involvement Scale (FEICS), Beck Depression Inventory (BDI), and Beck Anxiety Depression Inventory (BAI) were used at baseline. All subjects were followed for 12 months. The results of monthly urine tests and the treatment retention were recorded for further analysis.

RESULTS

Perceived criticism was correlated with depression (r=0.20, P<0.01). The overall retention rate in 12-month MMT was 54.70%. Lower perceived criticism (OR=1.84, 95% CI=1.20-3.60, P<0.01) and lower depression (OR=1.24, 95% CI=0.65-1.80, P=0.02) predicted longer retention in MMT.

CONCLUSION

EE, especially perceived criticism, has its influences on outcomes among heroin addicts in MMT. This suggested the potential benefits of family therapy among high EE heroin addicts in MMT. Furthermore, the mechanism how EE affects the outcome of MMT needs to be further investigated.

The reductions in monetary cost and gains in productivity with methadone maintenance treatment: one year follow-up

While methadone maintenance treatment (MMT) is beneficial for heroin dependence, there is little information regarding the reductions in monetary cost and gains in productivity following MMT. The aim of this study was to evaluate the changes in the monetary cost of heroin addiction and productivity after one year of MMT. Twenty-nine participants from an MMT clinic were included. The monetary cost, productivity, quality of life (QOL) and mental health status were assessed at both baseline and one year follow-up. The average annual total cost was approximately US$26,485 (1.43 GDP per capita in 2010) at baseline, and decreased by 59.3% to US$10,784 (0.58 GDP) at follow-up. The mean number of months of unemployment dropped from 6.03 to 2.79, the mean income increased to exceed the basic salary, but only reached 45.3% of the national average monthly earnings. The participants׳ mental health improved, but their QOL scores did not increase significantly. After one year of MMT, the monetary cost of heroin addiction fell, both the productivity and mental health of the participants׳ improved, but limited gains were seen with regard to their QOL.

Explicit and implicit heroin-related cognitions and heroin use among patients receiving methadone maintenance treatment

BACKGROUND

Craving is an important issue in substance use disorder. To achieve a better understanding of the cognitive processing systems of craving, the cognitive processes of craving have been considered as two distinct processes. One system, based on rule-based inferences and named explicit cognition, is more conscious and effortful. The other system, based on prior learned association and named implicit cognition, is unconscious and effortless. How explicit and implicit cognitions are associated with heroin use in patients with methadone maintenance treatment (MMT) is not clear. This study aimed to explore the relationship between explicit and implicit cognition and heroin use in patients undergoing MMT.

METHOD

This study recruited one-hundred forty intravenous heroin users. The participants were invited to provide social-demographic data, the severity of substance dependence and explicit cognition with regard to heroin. Then, participants completed a computerized test to assess implicit cognition with regards to heroin.

RESULTS

This study found that explicit and implicit heroin-related cognitions were associated with the frequency of heroin use. There was an interaction effect between implicit and explicit cognition on the frequency of heroin use. This study also found that higher explicit heroin-related cognition was a risk factor for continuing heroin use.

CONCLUSION

Both explicit and implicit cognitions were associated with the frequency of heroin use in patients undergoing MMT, but only explicit cognition was associated with whether patients could stop using heroin during MMT. Therefore, the status of heroin use in patients undergoing MMT may be related to different cognitive processes.

[Recovering helpers in the addiction treatment system in Hungary: an interpretative phenomenological analysis]

INTRODUCTION

The work of recovering helpers who work in the addiction rehabilitation centres was studied. The aim was to investigate the process of addicts becoming recovering helpers, and to study what peer help means to them.

METHODS

According to interpretative phenomenological analysis (IPA) design, subjects were selected, data were collected and analysed.

SUBJECTS

6 (5 males, 1 female), working as recovering helpers at least one year at addiction rehabilitation centres. Semi-structured life interviews were carried out and analysed according to IPA.

RESULTS

Emerging themes from the interviews were identified and summarized, then interpreted as central themes: important periods and turning points of the life story interviews: the experience of psychoactive drugs use, the development of the addiction (which became " Turning Point No 1") then the "rock bottom" experience ("Turning Point No 2"). Then the experience of the helping process was examined: here four major themes were identified: the development of the recovering self and the helping self, the wounded helper and the skilled helper, the experience of the helping process.

DISCUSSION

IPA was found to be a useful method for idiographic exploration of the development and the work of the recovering helpers. The work of the recovering helpers can be described as mentoring of the addict clients. Our experiences might be used for the training programs for recovering helpers as well as to adopt their professional role in addiction services.

Heroin Use, HIV-Risk, and Criminal Behavior in Baltimore: Findings from Clinical Research

This article reviews research conducted in Baltimore over the past 15 years, examining the following: (1) What factors differentiate heroin-addicted individuals who enter methadone treatment from those who do not? (2) How difficult is gaining access to methadone treatment? (3) What are effective ways to overcome barriers to treatment entry? (4) Why do so many methadone patients drop out of treatment prematurely? (5) What are the added benefits of counseling when coupled with methadone or buprenorphine treatment? (6) Does increasing access to treatment have an impact on overdose deaths? Specific recommendations are made for policymakers concerned with addressing heroin addiction.

Case records of the Massachusetts General Hospital. Case 35-2014: a 31-year-old woman with fevers, chest pain, and a history of HCV infection and substance-use disorder

A 31-year-old woman with substance-use disorder was admitted to this hospital because of fevers and chest pain. CT of the chest revealed multiple thick-walled nodular opacities throughout both lungs. Diagnostic tests were performed, and management decisions were made.

Evidence-based treatment for opioid disorders: a 23-year national study of methadone dose levels

Effective treatment for patients with opioid use problems is as critical as ever given the upsurge in heroin and prescription opioid abuse. Yet, results from prior studies show that the majority of methadone maintenance treatment (MMT) programs in the US have not provided dose levels that meet evidence-based standards. Thus, this paper examines the extent to which US MMT programs have made changes in the past 23 years to provide adequate methadone doses; we also identify factors associated with variation in program performance. Program directors and clinical supervisors of nationally-representative methadone treatment programs were surveyed in 1988 (n=172), 1990 (n=140), 1995 (n=116), 2000 (n=150), 2005 (n=146), and 2011 (n=140). Results show that the proportion of patients who received doses below 60 mg/day-the minimum recommended-declined from 79.5 to 22.8% in a 23-year span. Results from random effects models show that programs that serve a higher proportion of African-American or Hispanic patients were more likely to report low-dose care. Programs with Joint Commission accreditation were more likely to provide higher doses, as were a program that serves a higher proportion of unemployed and older patients. Efforts to improve methadone treatment practices have made substantial progress, but 23% of patients across the nation are still receiving doses that are too low to be effective.

Use of contingency management incentives to improve completion of hepatitis B vaccination in people undergoing treatment for heroin dependence: a cluster randomised trial

BACKGROUND

Poor adherence to treatment diminishes its individual and public health benefit. Financial incentives, provided on the condition of treatment attendance, could address this problem. Injecting drug users are a high-risk group for hepatitis B virus (HBV) infection and transmission, but adherence to vaccination programmes is poor. We aimed to assess whether contingency management delivered in routine clinical practice increased the completion of HBV vaccination in individuals receiving opioid substitution therapy.

METHODS

In our cluster randomised controlled trial, we enrolled participants at 12 National Health Service drug treatment services in the UK that provided opioid substitution therapy and nurse-led HBV vaccination with a super-accelerated schedule (vaccination days 0, 7, and 21). Clusters were randomly allocated 1:1:1 to provide vaccination without incentive (treatment as usual), with fixed value contingency management (three £10 vouchers), or escalating value contingency management (£5, £10, and £15 vouchers). Both contingency management schedules rewarded on-time attendance at appointments. The primary outcome was completion of clinically appropriate HBV vaccination within 28 days. We also did sensitivity analyses that examined vaccination completion with full adherence to appointment times and within a 3 month window. The trial is registered with Current Controlled Trials, number ISRCTN72794493.

FINDINGS

Between March 16, 2011, and April 26, 2012, we enrolled 210 eligible participants. Compared with six (9%) of 67 participants treated as usual, 35 (45%) of 78 participants in the fixed value contingency management group met the primary outcome measure (odds ratio 12·1, 95% CI 3·7-39·9; p<0·0001), as did 32 (49%) of 65 participants in the escalating value contingency management group (14·0, 4·2-46·2; p<0·0001). These differences remained significant with sensitivity analyses.

INTERPRETATION

Modest financial incentives delivered in routine clinical practice significantly improve adherence to, and completion of, HBV vaccination programmes in patients receiving opioid substitution therapy. Achievement of this improvement in routine clinical practice should now prompt actual implementation. Drug treatment providers should employ contingency management to promote adherence to vaccination programmes. The effectiveness of routine use of contingency management to achieve long-term behaviour change remains unknown.

FUNDING

National Institute for Health Research (RP-PG-0707-10149).

Extended-release naltrexone modulates brain response to drug cues in abstinent heroin-dependent patients

Drug cues play an important role in relapse to drug use. Naltrexone is an opioid antagonist that is used to prevent relapse in opioid dependence. Central opioidergic pathways may be implicated in the heightened drug cue-reactivity, but the effects of the opioid receptors' blockade on the brain responses to drug cues in opioid dependence are unknown. To pursue this question, we studied 17 abstinent i.v. heroin users with brain functional magnetic resonance imaging (fMRI) during exposure to visual heroin-related cues and matched neutral images before and 10-14 days after an injection of extended-release naltrexone (XRNTX). Whole brain analysis of variance of fMRI data showed main effect of XRNTX in the medial frontal gyrus, precentral gyrus, cuneus, precuneus, caudate and the amygdala. fMRI response was decreased in the amygdala, cuneus, caudate and the precentral gyrus and increased in the medial frontal gyrus and the precuneus. Higher plasma levels of naltrexone's major metabolite, 6-beta-naltrexol, were associated with larger reduction in the fMRI response to drug cues after XRNTX in the precentral, caudate and amygdala clusters. The present data suggest that XRNTX pharmacotherapy of opioid-dependent patients may, respectively, decrease and potentiate prefrontal and limbic cortical responses to drug cues and that this effect might be related to the XRNTX metabolism. Our findings call for further evaluation of the brain fMRI response to drug-related cues and of the 6-beta-naltrexol levels as potential biomarkers of XRNTX therapeutic effects in patients with opioid dependence.

Long term outcomes of pharmacological treatments for opioid dependence: does methadone still lead the pack?

The aim of this review was to update and summarize the scientific knowledge on the long term outcomes of the different pharmacological treatment options for opioid dependence currently available and to provide a critical discussion on the different treatment options based on these results. We performed a literature search using the PubMed databases and the reference lists of the identified articles. Data from research show that the three pharmacological options reviewed are effective treatments for opioid dependence with positive long term outcomes. However, each one has its specific target population and setting. While methadone and buprenorphine are first line options, heroin-assisted treatment is a second line option for those patients refractory to treatment with methadone with concomitant severe physical, mental, social and/or functional problems. Buprenorphine seems to be the best option for use in primary care offices. The field of opioid dependence treatment is poised to undergo a process of reinforcement and transformation. Further efforts from researchers, clinicians and authorities should be made to turn new pharmacological options into clinical reality and to overcome the structural and functional obstacles that maintenance programmes face in combatting opioid dependence.

Varenicline for smoking cessation among methadone-maintained smokers: a randomized clinical trial

BACKGROUND

With smoking rates far exceeding the general population, methadone-maintained (MMT) opiate-dependent smokers experience high rates of tobacco-related health consequences. Previous treatment studies have used nicotine replacement and produced low quit rates.

METHODS

We test, using a three-group randomized design, the efficacy of varenicline versus placebo, in comparison with nicotine replacement therapy (NRT) that combines nicotine patch prescription plus ad libitum nicotine rescue, for smoking cessation. We recruited methadone-maintained smokers from nine treatment centers in southern New England and provided six months of treatment, and a minimal behavioral intervention at baseline (NCI's 5A's). Outcomes included carbon monoxide (CO) confirmed 7-day point smoking cessation prevalence at 6 months and self-reported change in mean cigarettes per day.

RESULTS

The 315 participants had a mean age of 40, with 50% male and 79% non-Hispanic White, smoked an average of 19.6 (± 10.4) cigarettes/day, and had a mean daily methadone dose of 109 mg. Intent-to-treat analyses, with missing considered to be smoking, showed the rate of CO-confirmed 7-day abstinence at 6-months was 5.4% overall, with varenicline 3.7% compared to placebo 2.2%, and NRT 8.3% (p>.05). Adherence rates during the 7-days immediately prior to 6-month assessment were 34.2% in varenicline, 34.4% in placebo, and 48.8% in NRT. Between baseline and 6-months there was an overall self-reported mean reduction of 8.3 cigarettes/day.

CONCLUSION

Varenicline did not increase quit rates over placebo. Smoking cessation rates in methadone-maintained smokers are low and novel treatment strategies are required.

A day-by-day investigation of changes in criminal convictions before and after entering and leaving opioid maintenance treatment: a national cohort study

BACKGROUND

Opioid maintenance treatment (OMT) is associated with reduced crime among heroin users, but little is known about how crime changes during different phases of treatment. The aim of this study was to investigate changes in criminal convictions on a day-to-day basis before and after entry or discharge from OMT.

METHODS

National cohort study of all patients (n = 3221) in OMT in Norway 1997-2003. Patients were followed over a 9-year period, before, during, and after treatment. Criminal convictions were studied on a day-to-day basis in relation to treatment status. A time-continuous estimate of the probability of convictions within the population for all days during observation was calculated.

RESULTS

Changes in convictions were evident before changes of treatment status. During the 3 years prior to OMT, the convictions rate was approximately 0.4% per day. Prior to OMT, convictions decreased to about 0.2% per day on the day of treatment initiation. During the weeks before dropping out of treatment, convictions increased. The patterns during periods of transition were the same across gender, age and pre-treatment conviction-levels.

CONCLUSIONS

Changes in convictions often occurred prior to changes in treatment status. Reductions in criminal convictions were found in the period before entry (or re-entry) to OMT, and increases in criminal activity were found in the months prior to treatment interruption.