The development and internal validation of a multivariable model predicting 6-month mortality for people with opioid use disorder presenting to community drug services in England: a protocol

BACKGROUND

People with opioid use disorder have substantially higher standardised mortality rates compared to the general population; however, lack of clear individual prognostic information presents challenges to prioritise or target interventions within drug treatment services. Previous prognostic models have been developed to estimate the risk of developing opioid use disorder and opioid-related overdose in people routinely prescribed opioids but, to our knowledge, none have been developed to estimate mortality risk in people accessing drug services with opioid use disorder. Initial presentation to drug services is a pragmatic time to evaluate mortality risk given the contemporaneous routine collection of prognostic indicators and as a decision point for appropriate service prioritisation and targeted intervention delivery. This study aims to develop and internally validate a model to estimate 6-month mortality risk for people with opioid use disorder from prognostic indicators recorded at initial assessment in drug services in England.

METHODS

An English national dataset containing records from individuals presenting to drug services between 1 April 2013 and 1 April 2023 (n > 800,000) (the National Drug Treatment Monitoring System (NDTMS)) linked to their lifetime hospitalisation and death records (Hospital Episode Statistics-Office of National Statistics (HES-ONS)). Twelve candidate prognostic indicator variables were identified based on literature review of demographic and clinical features associated with increased mortality for people in treatment for opioid use disorder. Variables will be extracted at initial presentation to drug services with mortality measured at 6 months. Two multivariable Cox regression models will be developed one for 6-month all-cause mortality and one for 6-month drug-related mortality using backward elimination with a fractional polynomial approach for continuous variables. Internal validation will be undertaken using bootstrapping methods. Discrimination of both models will be reported using Harrel's c and d-statistics. Calibration curves and slopes will be presented comparing expected and observed event rates.

DISCUSSION

The models developed and internally validated in this study aim to improve clinical assessment of mortality risk for people with opioid use disorder presenting to drug services in England. External validation in different populations will be required to develop the model into a tool to assist future clinical decision-making.

Superiority and cost-effectiveness of Individual Placement and Support versus standard employment support for people with alcohol and drug dependence: a pragmatic, parallel-group, open-label, multicentre, randomised, controlled, phase 3 trial

Background

Individual Placement and Support (IPS) is a specialist intervention to help people attain employment in the open competitive labour market. IPS has been developed in severe mental illness and other disabilities, but it is of unknown effectiveness for people with alcohol and drug dependence. The Individual Placement and Support-Alcohol and Drug (IPS-AD) is the first superiority trial to evaluate effectiveness and cost-effectiveness.

Methods

IPS-AD was a pragmatic, parallel-group, multi-centre, randomised, controlled, phase 3 trial of standard employment support (treatment-as-usual [TAU]) versus IPS. IPS was offered as a single episode for up to 13 months. The study was done at seven community treatment centres for alcohol and drug dependence in England. Study participants were adults (18-65 years), who had been enrolled for at least 14 days in treatment for alcohol use disorder (AUD), opioid use disorder (OUD), or another drug use disorder (DUD; mostly cannabis and stimulants); were unemployed or economically inactive for at least six months; and wished to attain employment in the open competitive labour market. After random allocation to study interventions, the primary outcome was employment during 18-months of follow-up, analysed by mixed-effects logistic regression, using multiple imputation for the management of missing outcome data. There were two cost-effectiveness outcomes: a health outcome expressed as a quality adjusted life year (QALY) using £30,000 and £70,000 willingness-to-pay [WTP] thresholds; and additional days of employment, with a WTP threshold of £200 per day worked. The study was registered with ISRCTN (ISRCTN24159790) and is completed.

Findings

Between 8 May 2018 and 30 September 2019, 2781 potentially eligible patients were identified. 812 were excluded before screening, and 1720 participants were randomly allocated to TAU or IPS. In error, nine participants were randomised to study interventions on two occasions-so data for their first randomisation was analysed (modified intention-to-treat). A further 24 participants withdrew consent for all data to be used (full-analysis set therefore 1687 participants [70.1% male; mean age 40.8 years]; TAU, n = 844; IPS, n = 843 [AUD, n = 610; OUD, n = 837; DUD, n = 240]). Standard employment support was received by 559 [66.2%] of 844 participants in the TAU group. IPS was received by 804 [95.37%] of 843 participants in the IPS group. IPS was associated with an increase in attainment of employment compared with TAU (adjusted odds ratio [OR] 1.29; 95% CI 1.02-1.64; p-value 0.036). IPS was effective for the AUD and DUD groups (OR 1.48; 95% CI 1.14-1.92; p-value 0.004; OR 1.45, 95% CI 1.03-2.04, p-value 0.031, respectively), but not the OUD group. IPS returned an incremental QALY outcome gain of 0.01 (range 0.003-0.02) per participant with no evidence of cost-effectiveness at either WTP threshold-but QALY gains were cost-effective for the AUD and DUD groups at the £70,000 WTP threshold (probability 0.52 and 0.97, respectively). IPS was cost-effective for additional days of employment (probability 0.61), with effectiveness relating to the AUD group only (probability >0.99). Serious Adverse Events were reported by 39 participants (13 [1.5%] of 844 participants in the TAU group and 23 [2.7%] of 43 participants in the IPS group). There was a total of 25 deaths (1.5%; 9 in the TAU group and 16 in the IPS group)-none judged related to study interventions.

Interpretation

In this first superiority randomised controlled trial of IPS in alcohol and drug dependence, IPS helped more people attain employment in the open competitive labour market than standard employment support. IPS was cost-effective for a QALY health outcome (£70,000 WTP threshold) for the AUD and DUD groups, and for additional days of employment for the AUD group (£200 per day worked WTP threshold).

Funding

UK government Work and Health Unit.

Fatal opioid overdoses during and shortly after hospital admissions in England: A case-crossover study

BACKGROUND

Hospital patients who use illicit opioids such as heroin may use drugs during an admission or leave the hospital in order to use drugs. There have been reports of patients found dead from drug poisoning on the hospital premises or shortly after leaving the hospital. This study examines whether hospital admission and discharge are associated with increased risk of opioid-related death.

METHODS AND FINDINGS

We conducted a case-crossover study of opioid-related deaths in England. Our study included 13,609 deaths between January 1, 2010 and December 31, 2019 among individuals aged 18 to 64. For each death, we sampled 5 control days from the period 730 to 28 days before death. We used data from the national Hospital Episode Statistics database to determine the time proximity of deaths and control days to hospital admissions. We estimated the association between hospital admission and opioid-related death using conditional logistic regression, with a reference category of time neither admitted to the hospital nor within 14 days of discharge. A total of 236/13,609 deaths (1.7%) occurred following drug use while admitted to the hospital. The risk during hospital admissions was similar or lower than periods neither admitted to the hospital nor recently discharged, with odds ratios 1.03 (95% CI 0.87 to 1.21; p = 0.75) for the first 14 days of an admission and 0.41 (95% CI 0.30 to 0.56; p < 0.001) for days 15 onwards. 1,088/13,609 deaths (8.0%) occurred in the 14 days after discharge. The risk of opioid-related death increased in this period, with odds ratios of 4.39 (95% CI 3.75 to 5.14; p < 0.001) on days 1 to 2 after discharge and 2.09 (95% CI 1.92 to 2.28; p < 0.001) on days 3 to 14. 11,629/13,609 deaths (85.5%) did not occur close to a hospital admission, and the remaining 656/13,609 deaths (4.8%) occurred in hospital following admission due to drug poisoning. Risk was greater for patients discharged from psychiatric admissions, those who left the hospital against medical advice, and those leaving the hospital after admissions of 7 days or more. The main limitation of the method is that it does not control for time-varying health or drug use within individuals; therefore, hospital admissions coinciding with high-risk periods may in part explain the results.

CONCLUSIONS

Discharge from the hospital is associated with an acute increase in the risk of opioid-related death, and 1 in 14 opioid-related deaths in England happens in the 2 weeks after the hospital discharge. This supports interventions that prevent early discharge and improve linkage with community drug treatment and harm reduction services.

Acute impact of self-guided mental imagery on craving in cocaine use disorder: a mixed-methods analysis of a randomized controlled trial

Mental imagery manipulations are used to treat several psychological disorders, but their utility in treating cocaine use disorder (CUD) is unknown. Using prompted re-experiences and simulations with contrasting valence, we assessed the acute impact of a deliberate mental imagery task on cocaine craving.

DESIGN

A quantitative-qualitative 'mixed-methods' analysis of data collected for a randomized controlled trial that was stopped prematurely.

SETTING

UK National Health Service addictions treatment clinic and outpatient clinical research facility (laboratory).

PARTICIPANTS

Adults with CUD. The original target sample was 120. All participants enrolled at the point the original trial was stopped were included (38 enrolled, 31 completed study).

INTERVENTIONS

Personalized (3-minute) cue-exposure (handling cocaine paraphernalia and watching video of drug preparation), immediately followed by a single 5-minute, audio-recorded, self-guided and verbally described imagery task with random assignment to one of four conditions: two mental imagery memory re-experiences (positive image before initiation to cocaine use or a negative image of a 'worst time' adverse cocaine use episode) or two future simulations (positive theme of recovery from CUD or negative theme of worsened CUD).

MEASUREMENTS

Task transcripts were rated for imagery detail using five dimensions using a six-point scale of imagery detail (ID) (total score = 0-25) and thematically coded. The outcome measure was cocaine craving using the Craving Experiences Questionnaire-strengths version (CEQ-S11; score = 0-110) reported at baseline, arrival at the laboratory, and immediately after the cue-exposure and mental imagery tasks.

FINDINGS

A mixed-effects, longitudinal, restricted linear regression, with the past-positive imagery condition as referent, showed main effects of reduced craving after the imagery task (b = -29.2, 95% confidence interval (CI) = -45.3 to -13.1, P-value < 0.001) and increased craving for the future-negative task (b = 14.2, 95% CI = 0.1-28.4, P-value 0.049). There was a future-negative task by post-imagery craving interaction (b = 28.1, 95% CI = 0.1-56.1, P-value 0.049). A theory-driven, deductive/inductive qualitative analysis of the transcripts revealed six major themes: sensory characteristics, CUD vicious cycle, self-care, emotions and appraisals, social role and CUD recovery. Positively themed simulations included interpersonal connections and rewarding activity; negative images included personal adversity, with appraisals of self-criticism and hopelessness. Transcripts with more imagery detail were not associated with significantly greater reductions in craving in the positive or negative imagery task (r = -0.32, 95% CI = -0.69 to 0.13 and r = 0.06, 95% CI = -0.58 to 0.53, respectively).

CONCLUSION

In people with cocaine use disorder, after cue-exposure, a self-guided imagery task with positive themes reduced craving, whereas mental imagery simulating worsened cocaine use disorder did not appear to.

The hospital admission profile of people presenting to specialist addiction services with problematic use of alcohol or opioids: A national retrospective cohort study in England

BACKGROUND

Over the past decade in England the rate of alcohol and opioid-related hospitalisation has increased alongside a simultaneous reduction in people accessing specialist addiction treatment. We aimed to determine the hospitalisation patterns of people presenting to addiction treatment with problematic use of alcohol or opioids, and estimate how individual sociodemographic characteristics and hospital admission diagnoses are associated with the rate of hospitalisation, death and successful completion of addiction treatment.

METHODS

A national record linkage between Hospital Episode Statistics (HES) and the National Drug Treatment Monitoring System (NDTMS) captured lifetime hospital admission profiles of people presenting to addiction services in England in 2018/19. Latent class analysis assigned individuals to clusters based on the ICD-10 diagnosis coded as primary reason for admission. Negative binomial, and multilevel logistic regression models determined if outcomes differed due to sociodemographic characteristics or assigned diagnostic clusters.

FINDINGS

Inpatient data were available for 64,840 alcohol patients, and 107,296 opioid patients. The most common reasons for admission were alcohol withdrawal (n = 20,024 (5.3% of alcohol-cohort admissions)), and unspecified illness (n = 11,387 (2.1% of opioid-cohort admissions)). Seven diagnostic clusters were identified for each substance cohort. People with admissions predominantly relating to mental and behavioural disorders, and injuries or poisonings had significantly higher hospitalisation rates (adjusted IRR 7.06 (95%CI 6.72-7.42);p < 0.001), higher odds of death during addiction treatment (adjusted OR 2.71 (95%CI 2.29-3.20);p < 0.001) and lower odds of successful treatment completion (adjusted OR 0.72 (95%CI 0.68-0.76);p < 0.001).

INTERPRETATION

This is the first study to interrogate national hospitalisation patterns within people presenting to addiction services with problematic use of alcohol or opioids. Having identified high-risk, high-cost individuals with increased hospital usage, and increased odds of death, future work should focus on targeting appropriate interventions, to improve their health outcomes and prevent unnecessary hospital readmission.

FUNDING

The work was funded by the Medical Research Council (MRC).

Tobacco Smoking Rates in a National Cohort of People with Substance Use Disorder Receiving Treatment

BACKGROUND AND AIM

The prevalence of tobacco smoking among individuals receiving treatment for substance use disorder (SUD) remains high. Respiratory disease and other harms are of prime concern to health policy-makers, given the contributory role played by tobacco smoking in the excess rates of premature mortality seen in individuals with SUD. The aim was to use SUD treatment data to investigate tobacco smoking prevalence among subgroups of adults over the course of treatment.

METHODS

We used the English National Drug Treatment Monitoring System (NDTMS) to examine number of days tobacco had been smoked in the previous month in adults receiving SUD treatment (N = 106,472, median length of treatment 157 days).

RESULTS

At baseline (treatment start), 48.7% reported smoking tobacco; the highest rate was observed in opiate users (61%). Overall, the level of smoking at the latest assessment was 48.5%. Reductions (of between 5 and 7%) were observed among those who finished treatment but only within the final stages of treatment. A 5% increase in smoking was observed in those still in treatment within the study timeframe.

CONCLUSIONS

This study identifies the potential for a greater emphasis on reducing tobacco consumption within SUD treatment, for example, by offering all smokers within SUD treatment smoking cessation support as part of their SUD treatment programme.

National administrative record linkage between specialist community drug and alcohol treatment data (the National Drug Treatment Monitoring System (NDTMS)) and inpatient hospitalisation data (Hospital Episode Statistics (HES)) in England: design, method and evaluation

OBJECTIVES

The creation and evaluation of a national record linkage between substance misuse treatment, and inpatient hospitalisation data in England.

DESIGN

A deterministic record linkage using personal identifiers to link the National Drug Treatment Monitoring System (NDTMS) curated by Public Health England (PHE), and Hospital Episode Statistics (HES) Admitted Patient Care curated by National Health Service (NHS) Digital.

SETTING AND PARTICIPANTS

Adults accessing substance misuse treatment in England between 1 April 2018 and 31 March 2019 (n=268 251) were linked to inpatient hospitalisation records available since 1 April 1997.

OUTCOME MEASURES

Using a gold-standard subset, linked using NHS number, we report the overall linkage sensitivity and precision. Predictors for linkage error were identified, and inverse probability weighting was used to interrogate any potential impact on the analysis of length of hospital stay.

RESULTS

79.7% (n=213 814) people were linked to at least one HES record, with an estimated overall sensitivity of between 82.5% and 83.3%, and a precision of between 90.3% and 96.4%. Individuals were more likely to link if they were women, white and aged between 46 and 60. Linked individuals were more likely to have an average length of hospital stay ≥5 days if they were men, older, had no fixed residential address or had problematic opioid use. These associations did not change substantially after probability weighting, suggesting they were not affected by bias from linkage error.

CONCLUSIONS

Linkage between substance misuse treatment and hospitalisation records offers a powerful new tool to evaluate the impact of treatment on substance related harm in England. While linkage error can produce misleading results, linkage bias appears to have little effect on the association between substance misuse treatment and length of hospital admission. As subsequent analyses are conducted, potential biases associated with the linkage process should be considered in the interpretation of any findings.

TractaViewer: a genome-wide tool for preliminary assessment of therapeutic target druggability

SUMMARY

We present software to characterize and rank potential therapeutic (drug) targets with data from public databases and present it in a user-friendly format. By understanding potential obstacles to drug development through the gathering and understanding of this information, combined with robust approaches to target validation to generate therapeutic hypotheses, this approach may provide high quality targets, leading the process of drug development to become more efficient and cost-effective.

AVAILABILITY AND IMPLEMENTATION

The information we gather on potential targets concerns small-molecule druggability (ligandability), suitability for large-molecule approaches (e.g. antibodies) or new modalities (e.g. antisense oligonucleotides, siRNA or PROTAC), feasibility (availability of resources such as assays and biological knowledge) and potential safety risks (adverse tissue-wise expression, deleterious phenotypes). This information can be termed 'tractability'. We provide visualization tools to understand its components. TractaViewer is available from https://github.com/NeilPearson-Lilly/TractaViewer.

SUPPLEMENTARY INFORMATION

Supplementary data are available at Bioinformatics online.

Protocol for a multi-centre, definitive randomised controlled trial of the effectiveness of Individual Placement and Support for employment support among people with alcohol and drug dependence

BACKGROUND

Unemployment is highly prevalent in populations with alcohol and drug dependence and the employment support offered in addiction-treatment programmes is ineffective. Individual Placement and Support (IPS) is an evidence-based intervention for competitive employment. IPS has been extensively studied in severe mental illness and physical disabilities, but there have been no formal randomised controlled trials (RCTs) in alcohol and drug dependence. The Individual Placement and Support for Alcohol and Drug Dependence (IPS-AD) study should determine whether IPS for patients with alcohol use disorder (AUD), opioid use disorder (OUD) and other drug use disorder is effective.

DESIGN/METHODS

The IPS-AD study is a seven-site, pragmatic, two-arm, parallel-group, superiority RCT. IPS-AD includes a realist process evaluation. Eligible patients (adult, unemployed or economically inactive for at least 6 months and wishing to obtain open job market employment and enrolled in ongoing community treatment-as-usual (TAU; the control condition) in England for AUD, OUD and other drug use disorders) will be randomised (1:1) to receive TAU and any standard employment support, or TAU plus IPS (the experimental condition) for 9 months with up to 4 months of in-work support. The primary outcome measure will be competitive employment status (at least 1 day (7 h)) during an 18-month follow-up, determined by patient-level, trial-data-linkage with national tax and state benefit databases. From meta-analysis, an 18% target difference on this measure of vocational effectiveness (for the experimental intervention) and a two-sided 5% level of statistical significance, will require a minimum target sample of 832 participants to achieve 90% power for a pre-registered, mixed-effects, multi-variable logistic regression model. A maximum-likelihood multiple-imputation approach will manage missing outcome data. IPS-AD has six vocational secondary outcome measures during the 18-month follow-up: (1) total time in competitive employment (and corresponding National Insurance contributions and tax paid); (2) time from randomisation to first competitive employment; (3) number of competitive job appointments; (4) job tenure (length of longest held competitive employment); (5) sustained employment (tenure in a single appointment for at least 13 weeks); and (6) job search self-efficacy. A primary cost-benefit analysis and a secondary cost-effectiveness analysis will be done using the primary outcome and secondary vocational outcomes, respectively and will include addiction treatment and social and health outcomes and their associated reference costs. The process evaluation will address IPS implementation and delivery.

DISCUSSION

The IPS-AD study is the first large-scale, multi-site, definitive, superiority RCT of IPS for people with alcohol and drug dependence. Findings from the study will have substantial implications for service delivery.

TRIAL REGISTRATION

ISRCTN Registry, ID: ISRCTN24159790. Registered on 1 February 2018.

Medicines associated with dependence or withdrawal: a mixed-methods public health review and national database study in England

BACKGROUND

Antidepressants, opioids for non-cancer pain, gabapentinoids (gabapentin and pregabalin), benzodiazepines, and Z-drugs (zopiclone, zaleplon, and zolpidem) are commonly prescribed medicine classes associated with a risk of dependence or withdrawal. We aimed to review the evidence for these harms and estimate the prevalence of dispensed prescriptions, their geographical distribution, and duration of continuous receipt using all patient-linked prescription data in England.

METHODS

This was a mixed-methods public health review, comprising a rapid evidence assessment of articles (Jan 1, 2008, to Oct 3, 2018; with searches of MEDLINE, Embase, and PsycINFO, and the Cochrane and King's Fund libraries), an open call-for-evidence on patient experience and service evaluations, and a retrospective, patient-linked analysis of the National Health Service (NHS) Business Services Authority prescription database (April 1, 2015, to March 30, 2018) for all adults aged 18 years and over. Indirectly (sex and age) standardised rates (ISRs) were computed for all 195 NHS Clinical Commissioning Groups in England, containing 7821 general practices for the geographical analysis. We used publicly available mid-year (June 30) data on the resident adult population and investigated deprivation using the English Indices of Multiple Deprivation (IMD) quintiles (quintile 1 least deprived, quintile 5 most deprived), with each patient assigned to the IMD quintile score of their general practitioner's practice for each year. Statistical modelling (adjusted incident rate ratios [IRRs]) of the number of patients who had a prescription dispensed for each medicine class, and the number of patients in receipt of a prescription for at least 12 months, was done by sex, age group, and IMD quintile.

FINDINGS

77 articles on the five medicine classes were identified from the literature search and call-for-evidence. 17 randomised placebo-controlled trials (6729 participants) reported antidepressant-associated withdrawal symptoms. Almost all studies were rated of very low, low, or moderate quality. The focus of qualitative and other reports was on patients' experiences of long-term antidepressant use, and typically sudden onset, severe, and protracted withdrawal symptoms when medication was stopped. Between April 1, 2017, and March 31, 2018, 11·53 million individuals (26·3% of residents in England) had a prescription dispensed for at least one medicine class: antidepressants (7·26 million [16·6%]), opioids (5·61 million [12·8%]), gabapentinoids (1·46 million [3·3%]), benzodiazepines (1·35 million [3·1%]), and Z-drugs (0·99 million [2·3%]). For three of these medicine classes, more people had a prescription dispensed in areas of higher deprivation, with adjusted IRRs (referenced to quintile 1) ranging from 1·10 to 1·24 for antidepressants, 1·20 to 1·85 for opioids, and 1·21 to 1·85 for gabapentinoids across quintiles, and higher ISRs generally concentrated in the north and east of England. In contrast, the highest ISRs for benzodiazepines and Z-drugs were generally in the southwest, southeast, and east of England, with low ISRs in the north. Z-drugs were associated with increased deprivation, but only at the highest quintile (adjusted IRR 1·11 [95% CI 1·01-1·22]). For benzodiazepines, prescribing was reduced for people in quintiles 4 (0·90 [0·85-0·96]) and 5 (0·89 [0·82-0·97]). In March, 2018, for each of medicine class, about 50% of patients who had a prescription dispensed had done so continuously for at least 12 months, with the highest ISRs in the north and east. Long-term prescribing was associated with a gradient of increased deprivation.

INTERPRETATION

In 1 year over a quarter of the adult population in England had a prescription dispensed for antidepressants, opioids (for non-cancer pain), gabapentinoids, benzodiazepines, or Z-drugs. Long-term (>12 months) prescribing is common, despite being either not recommended by clinical guidelines or of doubtful efficacy in many cases. Enhanced national and local monitoring, better guidance for personalised care, and better doctor-patient decision making are needed.

FUNDING

Public Health England.

Mapping the hepatitis C cascade of care in people attending drug treatment services in England: A data linkage study

INTRODUCTION

Hepatitis C (HCV) infection in England primarily affects people who inject drugs (PWID). We describe persons HCV tested, estimate incidence and establish the cascade of care (CoC) for people engaging with drug services.

METHODS

Persons testing for HCV in drug services in Sentinel Surveillance of Blood Borne Virus Testing (SSBBV) between 2008 and 2016 were linked with people attending drug services in the National Drug and Treatment Monitoring System (NDTMS). We describe risk characteristics, establish the CoC, and estimate HCV incidence in PWID diagnosed in drug services.

RESULTS

Of 46,721 persons tested for anti-HCV in SSBBV in drug services, 29,773 (63.7%) linked to NDTMS. Of these, 9100 (30.6%) were antiV positive and anti-HCV positivity was 45.0% in persons reporting urgent housing problems and 43.8% in persons reporting ever injecting. Among persons anti-HCV positive, half had ≥1 positive anti-HCV test. For persons' first anti-HCV positive between 2008 and 2013 (n = 3123), 74.9% were HCV RNA tested, of whom 71.2% were RNA positive, and of these, 14.0% had evidence of interferon-based treatment, with 52.8% achieving cure. Among PWID, HCV incidence was 8.7 per 100 person-years (95% CI: 8.1-9.2).

CONCLUSION

Through record linkage of surveillance datasets, we estimated the HCV CoC for people attending drug services, providing a benchmark from which to monitor the impact of strategies to scale-up prevention, testing, and curative treatment with direct acting antivirals. Our study highlights wasteful repeated testing and poor linkage to care for this high risk population which need to be addressed.

Change in alcohol and other drug use during five years of continuous opioid substitution treatment

BACKGROUND

English national prospective, observational cohort study of patients continuously enrolled for five years in opioid substitution treatment (OST) with oral methadone and sublingual buprenorphine. This is a secondary outcome analysis of change in use of alcohol and other drug use (AOD) following identification of heroin use trajectories during OST.

METHODS

All adults admitted to community OST in 2008/09 and enrolled to 2013/14 (n = 7717). Data from 11 sequential, six-monthly clinical reviews were used to identify heroin and AOD use trajectories by multi-level Latent Class Growth Analysis. OST outcome in the sixth and seventh year was 'successful completion and no re-presentation' (SCNR) to structured treatment and was assessed using multi-level logistic regression.

RESULTS

With 'rapid decreasing' heroin use trajectory as referent, 'continued high-level' heroin use predicted 'continued high-level' crack cocaine use (relative risk ratio [RRR] 58.7; 95% confidence interval [CI] 34.2-100.5),'continued high-level' alcohol use (RRR 1.2; 95% CI 1.0-1.5), 'increasing' unspecified drug use (RRR 1.7; 95% CI 1.4-2.1) and less 'high and increasing' cannabis use (RRR 0.5; 95% CI 0.4-0.6). 'Increasing' crack use was negatively associated with SCNR outcome for the 'decreasing then increasing' and 'gradual decreasing' heroin use groups (adjusted odds ratio [AOR] 0.5; 95% CI 0.3-0.9 and AOR 0.2; 95% CI 0.1-0.7, respectively).

CONCLUSIONS

Continued high-level heroin use non-response during long-term OST is associated with high-level crack cocaine and alcohol use, increasing unspecified drug use, but less high and increasing cannabis use. Increasing use of crack cocaine is negatively associated with the likelihood that long-term OST is completed successfully.

Continuous opioid substitution treatment over five years: Heroin use trajectories and outcomes

BACKGROUND

This is the first national study in England of continuous long-term opioid substitution treatment (OST).

METHODS

All adults were admitted to community OST for opioid use disorder (OUD) in 2008/09 with continuous enrolment to 2013/14 (n = 7719). Heroin use trajectories were identified by multilevel Latent Class Growth Analysis. In Year 6 and 7 of follow-up, the outcome measure (analysed by multilevel, multivariable logistic regression) was 'successful completion and no re-presentation' (SCNR) to community treatment within six months.

RESULTS

Five heroin use trajectory classes were identified: 'gradual decreasing' (20.9%), 'decreasing then increasing' (21.7%), 'continued low-level' (17.0%), 'rapid decreasing' (25.6%), and 'continued high-level' (14.8%). At the end of Year 7, 4616 people (60.3%) remained in OST. Of those discharged, 28.8% achieved the SCNR follow-up outcome. SCNR was more likely in the 'gradual decreasing' (adjusted odds ratio [AOR] 2.40; 95% confidence interval [CI] 1.77-3.26), 'continued low-level' (AOR 2.46; CI 1.78-3.40), and 'rapid decreasing' (AOR 3.40; CI 2.43-4.37) classes relative to the 'continued high-level' class. SCNR was more likely among patients employed at admission (AOR 1.45; 95% CI 1.15-1.83) and those receiving adjunctive psychosocial interventions (AOR 1.44; 95% CI 1.03 to 2.02).

CONCLUSIONS

Among English patients in OST for 5 years, heroin use trajectories were clearly delineated with a gradient of response on the study outcome. Successful completion and no re-presentation was achieved by 28.8% of discharged patients. The rapid decreasing trajectory had the greatest likelihood of positive outcome. Adjunctive psychosocial intervention during OST was associated with positive outcome.

Effectiveness of community psychosocial and pharmacological treatments for alcohol use disorder: A national observational cohort study in England

BACKGROUND

This was a national English observational cohort study using administrative data to estimate the effectiveness of community pharmacological and psychosocial treatment for alcohol use disorder (AUD).

METHODS

All adults commencing AUD treatment in the community reported to the National Drug Treatment Monitoring System (April 1 2014-March 31 2015; N = 52,499). Past 28-day admission drinking pattern included drinks per drinking day (DDD): 0 ('Abstinent'), 1-15 ('Low-High'), 16-30 ('High-Extreme') and over 30 DDD ('Extreme'). The primary outcome was successful completion of treatment within 12 months of commencement with no re-presentation (SCNR) in the subsequent six months, analysed by multi-level, mixed effects, multivariable logistic regression.

RESULTS

The majority reported DDD in the 'Low-High' (n = 17,698, 34%) and 'High-Extreme' (n = 21,383, 41%) range. Smaller proportions were categorised 'Extreme' (n = 7759, 15%) and 'Abstinent' (n = 5661, 11%). Three-fifths (58%) achieved SCNR. Predictors of SCNR were older age, black/minority ethnic group, employment, criminal justice system referral, and longer treatment exposure. Predictors of negative outcome were AUD treatment history, lower socio-economic status, housing problems, and 'Extreme' drinking at admission. In addition to psychosocial interventions, pharmacological interventions and recovery support increased the likelihood of SCNR. Pharmacological treatment was only beneficial for the 'Low-High' groups with recovery support.

CONCLUSIONS

Over half of all patients admitted for community AUD treatment in England are reported to successfully complete treatment within 12 months and are not re-admitted for further treatment in the following 6 months. Study findings underscore efforts to tailor AUD treatment to the severity of alcohol consumption and using recovery support.

Memory-Focused Cognitive Therapy for Cocaine Use Disorder: Theory, Procedures and Preliminary Evidence From an External Pilot Randomised Controlled Trial

BACKGROUND

Cocaine use disorder (CUD) is a debilitating condition with no NICE-recommended medication or specific psychosocial interventions. In the United Kingdom (UK), general counselling (treatment-as-usual; TAU) is widely delivered, but has limited effectiveness. We tested the feasibility, safety and preliminary efficacy of a novel, adjunctive psychosocial intervention for CUD, called 'memory-focused cognitive therapy' (MFCT).

METHODS

We did a two-arm, external pilot randomised controlled trial at a specialist community National Health Service addictions clinic in London, UK. 30 adults (≥18years), voluntarily seeking treatment for CUD (enrolled ≥14days; all with moderate-to-severe DSM5 CUD), were individually randomised (1:1) to a control group (ongoing TAU; 3×90min CUD cognitive conceptualisation assessments; 2×30min cocaine-related cue-induction procedures; and 3×30min research follow-ups); or to an intervention group (ongoing TAU; 3×90min cognitive conceptualisation assessments; 2×30min cocaine-related cue-induction procedures; 5×120min, one-to-one, MFCT sessions [in 1week]; and 3×60min research follow-ups and MFCT-relapse prevention). The primary outcome was the total percentage score on the frequency version of the Craving Experiences Questionnaire (CEQ-F) at 1-month follow-up after the intensive intervention week (clinical endpoint; recall period past 2weeks; higher score indicating greater craving). Secondary outcomes at the 1-month follow-up were percentage days abstinent (PDA) from cocaine, and longest period (days) of continuous abstinence (LPA) in the prior 28days. Outcomes were analysed as an unadjusted group mean difference (with Hedge's g effect size [ES]) and a 95% Confidence Interval [CI] for the primary outcome and a 90% CI for the secondary outcomes. Exploratory, multivariable linear (primary outcome) and Poisson regression models (secondary outcomes), with sex, age, months of regular cocaine use, baseline outcome score, and group estimated the effectiveness of the intervention. The trial is registered with the ISCRTN (ISRCTN16462783).

FINDINGS

Between July 15, 2015, and November 27, 2016, 58 patients were assessed for eligibility and 30 participants were randomised (14 to the control group and 16 to the intervention). With outcome data collected for all participants at the endpoint, the intervention group mean CEQ-F score (14·77; SD 21·47) was lower than the control group mean (51·75; SD 22·72); ES -1·62; 95% CI -2·45 to -0·80. MFCT was associated with more cocaine abstinence in the intervention group (PDA 85·94; SD 18·96) than the control group (PDA 54·59; SD 30·29); ES 1·19; 90% CI 0·54 to 1·84. There was also greater maximum abstinence in the intervention group (LPA 15·69; SD 10·10) than the control group (6·00; SD 7·36); ES 1·06; 90% CI 0·41 to 1·70. Exploratory, confounder-adjusted regression models for this preliminary effect supported the treatment association for reduced craving experiences (CEQ-F Coef. -28·25; 95% CI -45·15 to -11·35); more abstinence (PDA Incidence Rate Ratio [IRR] 1·56; 95% CI 1·31 to 1·88); and greater maximum abstinence (LPA IRR 2·56; 95% CI 1·96 to 3·35), although relative weak unmeasured confounding could overturn these model-adjusted exposure-outcome associations. There were four serious adverse events (among three participants). None were judged related to study procedures or interventions.

INTERPRETATION

In this first external pilot randomised controlled trial of MFCT for CUD, we have shown that the intervention and control procedures and acceptable feasible and safe, and report preliminary evidence that MFCT is associated with reduced craving and increased abstinence. These findings support progression to a substantive trial.

FUNDING SOURCE

UK National Institute for Health Research, Biomedical Research Centre.

Memory-focused cognitive therapy for cocaine use disorder: Rationale, design and protocol for an external pilot randomised controlled trial

INTRODUCTION

Cocaine use disorder (CUD) is a debilitating condition characterised by maladaptive cocaine-related memories and impaired cognitive and behavioural control. There are no evidence-supported pharmacotherapies and only weakly effective psychological interventions specific for CUD. Our novel Memory-focused Cognitive Therapy (MFCT) aims to modify cocaine-related memories to reduce craving and drug use.

METHODS

This is a single-centre (outpatient), 15-week, two-arm, pilot randomised controlled trial (RCT) to address feasibility, safety, quality and preliminary efficacy. Thirty participants (adults ≥18 years; current CUD) will receive ongoing standard care (treatment-as-usual [TAU]) during the study and will be randomised (1:1) to a control or intervention group. The control group will receive 3 × 90min CUD cognitive case conceptualisation assessments and 2 × 30min cocaine-related cue-induction procedures (in vivo presentation of images and objects). Experimental group participants will receive 3 × 90min CUD cognitive case conceptualisation assessments; 2 × 30min cue-induction procedures; and individual MFCT (5 × 120min; daily for 1 week; with 3 relapse prevention follow-ups over 3-months). All study participants will complete research follow-ups at 1-week, 1-month and 3-months. The experimental and control groups will be compared on the mean score on the frequency version of the Craving Experience Questionnaire at 1-month (primary outcome measure). Secondary outcomes include: percentage of days abstinent and longest period of continuous abstinence from cocaine (past 28-days at 1-month follow-up); urine drug screen and CUD diagnosis (DSM-5).

CONCLUSIONS

We will conduct a full external pilot RCT of a novel, MFCT for CUD. The findings will inform the case, and necessary modifications, for a substantive study.

Tracking progressive pathological and functional decline in the rTg4510 mouse model of tauopathy

BACKGROUND

The choice and appropriate use of animal models in drug discovery for Alzheimer's disease (AD) is pivotal to successful clinical translation of novel therapeutics, yet true alignment of research is challenging. Current models do not fully recapitulate the human disease, and even exhibit various degrees of regional pathological burden and diverse functional alterations. Given this, relevant pathological and functional endpoints must be determined on a model-by-model basis. The present work explores the rTg4510 mouse model of tauopathy as a case study to define best practices for the selection and validation of cognitive and functional endpoints for the purposes of pre-clinical AD drug discovery.

METHODS

Male rTg4510 mice were first tested at an advanced age, 12 months, in multiple behavioural assays (step 1). Severe tau pathology and neurodegeneration was associated with profound locomotor hyperactivity and spatial memory deficits. Four of these assays were then selected for longitudinal assessment, from 4 to 12 months, to investigate whether behavioural performance changes as a function of accumulation of tau pathology (step 2). Experimental suppression of tau pathology-via doxycycline administration-was also investigated for its effect on functional performance.

RESULTS

Progressive behavioural changes were detected where locomotor activity and rewarded alternation were found to most closely correlate with tau burden and neurodegeneration. Doxycycline initiated at 4 months led to a 50% suppression of transgene expression, which was sufficient to prevent subsequent increases in tau pathology and arrest related functional decline.

CONCLUSIONS

This two-step approach demonstrates the importance of selecting assays most sensitive to the phenotype of the model. A robust relationship was observed between pathological progression, development of phenotype, and their experimental manipulation-three crucial factors for assessing the translational relevance of future pre-clinical findings.

Young People's Use of E-Cigarettes across the United Kingdom: Findings from Five Surveys 2015-2017

Concern has been expressed about the use of e-cigarettes among young people. Our study reported e-cigarette and tobacco cigarette ever and regular use among 11-16 year olds across the UK. Data came from five large scale surveys with different designs and sampling strategies conducted between 2015 and 2017: The Youth Tobacco Policy Survey; the Schools Health Research Network Wales survey; two Action on Smoking and Health (ASH) Smokefree Great Britain-Youth Surveys; and the Scottish Schools Adolescent Lifestyle and Substance Use Survey. Cumulatively these surveys collected data from over 60,000 young people. For 2015/16 data for 11-16 year olds: ever smoking ranged from 11% to 20%; regular (at least weekly) smoking between 1% and 4%; ever use of e-cigarettes 7% to 18%; regular (at least weekly) use 1% to 3%; among never smokers, ever e-cigarette use ranged from 4% to 10% with regular use between 0.1% and 0.5%; among regular smokers, ever e-cigarette use ranged from 67% to 92% and regular use 7% to 38%. ASH surveys showed a rise in the prevalence of ever use of e-cigarettes from 7% (2016) to 11% (2017) but prevalence of regular use did not change remaining at 1%. In summary, surveys across the UK show a consistent pattern: most e-cigarette experimentation does not turn into regular use, and levels of regular use in young people who have never smoked remain very low.

Does exposure to opioid substitution treatment in prison reduce the risk of death after release? A national prospective observational study in England

BACKGROUND AND AIMS

People with opioid use disorder (OUD) in prison face an acute risk of death after release. We estimated whether prison-based opioid substitution treatment (OST) reduces this risk.

DESIGN

Prospective observational cohort study using prison health care, national community drug misuse treatment and deaths registers.

SETTING

Recruitment at 39 adult prisons in England (32 male; seven female) accounting for 95% of OST treatment in England during study planning.

PARTICIPANTS

Adult prisoners diagnosed with OUD (recruited: September 2010-August 2013; first release: September 2010; last release: October 2014; follow-up to February 2016; n = 15 141 in the risk set).

INTERVENTION AND COMPARATOR

At release, participants were classified as OST exposed (n = 8645) or OST unexposed (n = 6496). The OST unexposed group did not receive OST, or had been withdrawn, or had a low dose.

MEASUREMENTS

Primary outcome: all-cause mortality (ACM) in the first 4 weeks.

SECONDARY OUTCOMES

drug-related poisoning (DRP) deaths in the first 4 weeks; ACM and DRP mortality after 4 weeks to 1 year; admission to community drug misuse treatment in the first 4 weeks. Unadjusted and adjusted Cox regression models (covariates: sex, age, drug injecting, problem alcohol use, use of benzodiazepines, cocaine, prison transfer and admission to community treatment), tested difference in mortality rates and community treatment uptake.

FINDINGS

During the first 4 weeks after prison release there were 24 ACM deaths: six in the OST exposed group and 18 in the OST unexposed group [mortality rate 0.93 per 100 person-years (py) versus 3.67 per 100 py; hazard ratio (HR) = 0.25; 95% confidence interval (CI) = 0.10-0.64]. There were 18 DRP deaths: OST exposed group mortality rate 0.47 per 100 py versus 3.06 per 100 py in the OST unexposed group (HR = 0.15; 95% CI = 0.04-0.53). There was no group difference in mortality risk after the first month. The OST exposed group was more likely to enter drug misuse treatment in the first month post-release (odds ratio 2.47, 95% CI = 2.31-2.65). The OST mortality protective effect on ACM and DRP mortality risk was not attenuated by demographic, overdose risk factors, prison transfer or community treatment (fully adjusted HR = 0.25; 95% CI = 0.09-0.64 and HR = 0.15; 95% CI = 0.04-0.52, respectively).

CONCLUSIONS

In an English national study, prison-based opioid substitution therapy was associated with a 75% reduction in all-cause mortality and an 85% reduction in fatal drug-related poisoning in the first month after release.

Effectiveness of treatment for opioid use disorder: A national, five-year, prospective, observational study in England

BACKGROUND

This the first 5-year effectiveness study of publicly funded treatment for opioid use disorder (OUD) in England.

METHODS

All adults initiating treatment in 2008/09 in all 149 local treatment systems reporting to the National Drug Treatment Monitoring System (n=54,347). Admission polydrug use sub-populations were identified by Latent Class Analysis. The treatment outcome measure was 'successful completion and no re-presentation within six months' (SCNR) analysed by multilevel, multivariable logistic regression and funnel plots to contrast outcome by treatment system.

RESULTS

SCNR was achieved by 21.9%. Heroin and crack cocaine users were significantly less likely to achieve this outcome than patients who used heroin only (adjusted odds ratio [AOR] 0.90; 95% confidence interval [CI] 0.85-0.95). Older patients (AOR 1.09; CI 1.07-1.11), those employed (AOR 1.27; CI 1.18-1.37) and those enrolled for longer treatment were more likely to achieve the outcome measure. After risk adjustment, the local treatment systems that achieved substantially better outcome performance (14/149) had a lower rate of opiate prevalence in the local population at time of study initiation (incidence rate difference [IRD] 4.1; CI 4.0-4.2), fewer criminal offences per thousand (IRD 28.5; CI 28.1-28.8) and lower drug-related deaths per million (IRD 5.9; CI 5.9-5.9).

CONCLUSIONS

In an English national study, one fifth of patients successful completed treatment for OUD and did not present for further treatment within six months. Longer time in treatment increases the probability of achieving and maintaining clinical benefit from treatment. After risk-adjustment, an important minority of treatment systems achieve substantially better outcome performance.

Is treatment for alcohol use disorder associated with reductions in criminal offending? A national data linkage cohort study in England

BACKGROUND

This is the first English national study of change in criminal offending following treatment for alcohol use disorder (AUD).

METHODS

All adults treated for AUD by all publicly funded treatment services during April 2008-March 2009 (n=53,017), with data linked to the Police National Computer (April 2006-November 2011). Pre-treatment offender sub-populations were identified by Latent Profile Analysis. The outcome measure was the count of recordable criminal offences during two-year follow-up after admission. A mixed-effects, Poisson regression modelled outcome, adjusting for demographics and clinical information, the latent classes, and treatment exposure covariates.

RESULTS

Twenty-two percent of the cohort committed one or more offences in the two years pre-treatment (n=11,742; crude rate, 221.5 offenders per 1000). During follow-up, the number of offenders and offences fell by 23.5% and 24.0%, respectively (crude rate, 69.4 offenders per 1000). During follow-up, a lower number of offences was associated with: completing treatment (adjusted incident rate ratio [IRR] 0.82; 95% confidence interval [CI] 0.79-0.85); receiving inpatient detoxification (IRR 0.84; CI 0.80-0.89); or community pharmacological therapy (IRR 0.89; CI 0.84-0.96). Reconviction was reduced in the sub-population characterised by driving offences (n=1,140; 11.7%), but was relatively high amongst acquisitive (n=768; 58.3% reconvicted) and violent offending sub-populations (n=602; 77.6% reconvicted).

CONCLUSIONS

Reduced offending was associated with successful completion of AUD treatment and receiving inpatient and pharmacological therapy, but not enrolment in psychological and residential interventions. Treatment services (particularly those providing psychological therapy and residential care) should be alert to offending, especially violent and acquisitive crime, and enhance crime reduction interventions.

A population PK model for citalopram and its major metabolite, N-desmethyl citalopram, in rats

A population PK model was developed in order to simultaneously describe citalopram and its major metabolite, n-desmethyl citalopram, plasma concentrations in two different strain of rats after intravenous (IV) and oral (PO) administration of citalopram. Citalopram was administered to Sprague-Dawley (SD) rats at doses: 0.3, 1, 3, and 10 mg/kg IV and 10 mg/kg PO. The compound was dosed orally to Wistar rats at doses: 0.3, 1, 3, 10, 30 and 60 mg/kg. Plasma samples were collected for citalopram and metabolite. Pharmacokinetic analyses were conducted using NONMEM 7.2. Values below the quantification limit (BLQ < 0.1 ng/mL) were included in the analyses and treated as censored information. The disposition of citalopram was best described by a 3-compartment model and its desmethyl metabolite by a 2-compartment model. Several models for the absorption rate were explored (e.g. first, zero order and combined first and zero order absorption, Michaelis-Menten, lag time) in combination with dose and/or time dependent covariate effects. Dose dependent oral bioavailability properties were also identified in this analysis. Citalopram IV clearance and metabolite formation rate were adequately described as linear processes. Metabolite clearance was adequately described using a Michaelis-Menten clearance with different parameters depending on the strain. This analysis demonstrates a very complex absorption/metabolism process explaining the highly non-linear pharmacokinetics observed across all the doses. This is the first combined parent/metabolite population PK analysis in both SD and Wistar rats over a wide range of IV and PO dosages for citalopram, a compound that exhibits highly nonlinear oral pharmacokinetics in rats.

Fatal opioid poisoning: a counterfactual model to estimate the preventive effect of treatment for opioid use disorder in England

AIM

A counterfactual model was used to estimate the number of fatal opioid-related poisonings prevented by public treatment services for opioid use disorder (OUD) in England between April 2008 and March 2011.

METHODS

Patient OUD treatment episode data recorded by the English National Drug Treatment Monitoring System were linked to data on opioid deaths recorded by the Office for National Statistics. The source population was the official estimate of non-medical opioid users (aged 15-64 years; approximately 260 000 each year). The target population was all individuals (aged 15-64 years) treated for OUD in the study period (n = 220 665). The outcome measure was fatal opioid-related poisoning (opioid death). The opioid death rate [per 100 person-years (PY)] and mortality rate ratios (MRR) were computed for study year, age group (15-24, 25-34, 35-64 years) and for three treatment-related states: time spent 'prior to treatment', 'during treatment' and 'after treatment'.

RESULTS

Between April 2008 and March 2011, there were 3731 opioid deaths in the study: 741 during treatment (0.20 per 100 PY; referent category); 2722 prior to treatment [0.77 per 100 PY; MRR = 3.76, 95% confidence interval (CI) = 3.18-4.44]; and 268 after treatment (0.41 per 100 PY; MRR = 1.99, 95% CI = 1.64-2.41). By counterfactual estimation, national OUD treatment services prevented an average of 880 opioid deaths each year (95% CI = 702-1084).

CONCLUSIONS

Between April 2008 and March 2011, a counterfactual model shows that the English public treatment system for opioid use disorder prevented an average of 880 deaths each year from opioid-related poisoning. Counterfactual models of mortality prevention can be used for outcome and performance monitoring of substance use disorder treatment systems.

Development of the Addiction Dimensions for Assessment and Personalised Treatment (ADAPT)

BACKGROUND

Convergent research reveals heterogeneity in substance use disorders (SUD). The Addiction Dimensions for Assessment and Personalised Treatment (ADAPT) is designed to help clinicians tailor therapies.

METHODS

Multicentre study in 21 SUD clinics in London, Birmingham (England) and Adelaide (Australia). 132 clinicians rated their caseload on a beta version with 16 ordinal indicators of addiction severity, health and social problem complexity, and recovery strengths constructs. In Birmingham, two in-treatment outcomes were recorded after 15-months: 28-day drug use (Treatment Outcome Profile; n=703) and Global Assessment of Functioning (GAF; DSM-IV Axis V; n=695). Following item-level screening (inter-rater reliability [IRR]; n=388), exploratory structural equation models (ESEM), latent profile analysis (LPA), and mixed-effects regression evaluated construct, concurrent and predictive validity characteristics, respectively.

RESULTS

2467 patients rated (majority opioid or stimulant dependent, enrolled in opioid medication assisted or psychological treatment). IRR-screening removed two items and ESEM models identified and recalibrated remaining indicators (root mean square error of approximation 0.066 [90% confidence interval 0.055-0.064]). Following minor re-specification and satisfactory measurement invariance evaluation, ADAPT factor scores discriminated patients by sample, addiction therapy and drug use. LPA identified three patient sub-types: Class 1 (moderate severity, moderate complexity, high strengths profile; 46.9%); Class 2 (low severity, low complexity, high strengths; 25.4%) and Class 3 (high severity, high complexity, low strengths; 27.7%). Class 2 had higher GAF (z=4.30). Class 3 predicted follow-up drug use (z=2.02) and lower GAF (z=3.51).

CONCLUSION

The ADAPT is a valid instrument for SUD treatment planning, clinical review and outcome evaluation. Scoring and application are discussed.

Ultra-rapid screening for substance-use disorders: the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST-Lite)

BACKGROUND

The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST 3.0; index test) is a structured interview for alcohol, tobacco, cannabis, stimulants, sedatives and opioid use disorders in general medical settings. Perceived administration time deters routine use. This study releases a short-form: the ASSIST-Lite.

METHODS

Diagnostic accuracy study among 2082 adults recruited from general medical (70%) and specialist mental health/addiction treatment services (22%). Current DSM-IV substance dependence (MINI International Neuropsychiatric Interview) and moderate-severe tobacco dependence (Fagerstrom Nicotine Dependence Test) were reference standards. Exploratory factor and item-response theory models re-calibrated ordinal test items. Items for the ASSIST-Lite were selected by diagnostic accuracy evaluation (area under the receiver-operating characteristic [AUC] curve [≤0.7]), sensitivity, specificity, positive and negative predictive values [PVP, NVP], kappa, likelihood ratios [LR+, LR-], and clinical utility index [CU+, CU-]).

RESULTS

For each substance an item pair was selected (AUC [0.8-1.0], sensitivity [0.8-1.0], specificity [0.7-0.8], PVP [0.8-1.0], NVP [0.7-1.0], kappa [0.5-0.9], LR+ [2.5-5.9], LR- [0.0-0.2], CU+ [0.7-0.9], and CU- [0.5-0.8]). Gender, age and recruitment setting (specialist mental health versus general medical) did not moderate accuracy, with the exception of opioids (AUC <0.7, participants ≥59 years). Male opioid users had more severe substance involvement scores that females (differential item functioning analysis, P=0.00). There was no evidence of differential accuracy between countries (AUC range, 0.8-1.0).

CONCLUSION

The ASSIST-Lite is an ultra-rapid screener which has been optimised for general medical settings. Optionally, a criterion question can be added to capture hazardous drinking, and to capture use of another type of mood-altering substance.

Risk adjustment of heroin treatment outcomes for comparative performance assessment in England

AIMS

Variability in effectiveness of treatment for substance abuse disorder (SUD) is an important and understudied issue. This study aimed to quantify the extent of outcome variability in the English SUD treatment system after adjusting for potential confounding variables.

DESIGN

Prospective cohort study using data from the English national drug treatment outcome monitoring database.

SETTING

All 149 administrative areas delivering publicly funded SUD services in the National Health Service and non-governmental sector.

PARTICIPANTS

New adult admissions between January 2008 and October 2010 with illicit heroin-related problems in all administrative areas, with an in-treatment review conducted between 5 and 26 weeks (mean = 129.5 days; SD = 40.0) up to 30 April 2011 (n = 65 223; 75.6% of eligible clients). Individuals were divided randomly to form model developmental and internal validation samples. These were contrasted with an independent (external) sample of the same population admitted to treatment between November 2010 and April 2011 and followed to 31 October 2011 (n = 13 797; 81.4% of those eligible).

MEASUREMENTS AND ANALYSIS

The outcome measure was self-reported illicit heroin use, categorized as abstinent or deteriorated (the latter by Reliable Change Index), each risk-adjusted by person-level (demographics, clinical severity and treatment complexity) and area-level (SUD prevalence, social deprivation and severity averages) covariates by multivariable logistic regression using multiply imputed outcome and covariate data. Risk-adjusted models were assessed by information criteria and discrimination (c-index). Standardized outcome rates were compared by funnel plot with 95% and 99% control limits.

FINDINGS

Models of heroin abstinence (48.4%) and deterioration (3.2%) were comparable across the developmental and validation samples (c-index = 0.70-0.71 and 0.82-0.87), with 79.2 and 94.0%, respectively, of the 149 treatment areas falling within 95% control limits. At the 99% limit, seven areas (4.7%) achieved abstinence rates above the national average, and eight had relatively poor abstinence rates (5.4%). At the 99% control limit, one area achieved very low deterioration outcomes and two (1.3%) were worse that the average. Risk adjustment served to increase abstinence rates in good performing areas by 0.63% and reduce abstinence rates by 0.37% in poor performing areas, and by 0.12% and 0.18%, respectively, for deterioration.

CONCLUSION

There is some exceptional variability in the apparent effectiveness of the English treatment system for substance use disorders. It is important to determine the source of this variability in order to inform drug treatment delivery and its evaluation both in England and overseas.

How best to measure change in evaluations of treatment for substance use disorder

AIMS

To compare the performance of the Jacobson & Truax (JT) reliable change index (RCI) with three alternative methods, using data from individuals receiving treatment for substance use disorders.

DESIGN

English National Treatment Outcome Monitoring Database for publicly funded specialist community pharmacological and psychosocial interventions.

PARTICIPANTS

New adult admissions to treatment across England (1 January-31 December 2008), with in-treatment clinic progress review conducted after an average of 122.8 days for 18,163 individuals.

MEASUREMENTS

Self-reported days using heroin, crack, cocaine powder and alcohol during the 4 weeks before admission and clinical review, recorded using the Treatment Outcomes Profile and analysed using a multi-level, mixed-linear model, with both observed and true scores to estimate the effect of regression to the mean (RTM). Differences in performance among the JT RCI and the alternative methods were assessed by the proportion assigned to a reliably 'improved', 'unchanged' or 'reliably deteriorated' category; level of agreement; difference in effect size for observed and true scores; and receiver operating characteristic parameters.

FINDINGS

When compared to the alternative methods, the JT RCI was more conservative in assigning individuals to the improved category, and it showed no evidence of inferiority on any measure. For each method, all individuals categorized as reliably deteriorated and the majority of those categorized reliably improved had outcome scores which fell beyond that expected by RTM. Substituting true scores for observed scores moderated the size of the change effect associated with reduced use of the four substances, but this remained statistically significant.

CONCLUSIONS

The Jacobson & Truax Reliable Change Index appears to be the optimal measure of change for evaluations of treatment for substance use disorder, in that it is the most conservative for assessing improvement and at least as accurate on all other criteria. Any evaluation of change needs to take account of regression to the mean.

Effectiveness of community treatments for heroin and crack cocaine addiction in England: a prospective, in-treatment cohort study

BACKGROUND

Addiction to heroin and crack cocaine is debilitating and persistent, but such disorders are treatable. We present the first effectiveness study of the main community interventions for addiction to heroin and crack cocaine in England, using data from the National Drug Treatment Monitoring System (NDTMS).

METHODS

The study cohort consisted of all adults with a heroin or crack cocaine addiction, or both, who started pharmacological treatment (n=18 428 patients) or psychosocial treatment (n=2647) between Jan 1 and Nov 30, 2008, received at least 6 months' treatment or were discharged by the study endpoint (May 31, 2009), and had outcome data submitted to the NDTMS. Effectiveness was assessed from change in days of heroin or crack cocaine use, or both in the 28 days before the start of treatment and in the 28 days before review.

FINDINGS

14 656 clients-74% of the cohort eligible for analysis at review with available data-were analysed at the study endpoint. During the 28 days before review, 37% (5016/13 542) of heroin users abstained from heroin and 52% (3941/7636) of crack cocaine users abstained from crack cocaine. A higher proportion of users of heroin only abstained than did users of both heroin and crack cocaine (42% [2465/5863] vs 33% [2551/7679]; OR 1.46, 95% CI 1.36-1.56), and more users of crack cocaine only abstained than did users of both drugs (57% [295/522] vs 51% [3646/7114]; 1.24, 1.03-1.48). Overall heroin use reduced by 14.5 days (95% CI 14.3-14.7) and crack cocaine use by 7.7 days (7.5-7.9). For clients given pharmacological treatment, reduction in days of heroin use was smaller for users of both heroin and crack cocaine than for users of heroin alone (p<0.0001), but this differential effectiveness was not recorded for psychosocial treatment in heroin or crack cocaine users compared with users of both drugs.

INTERPRETATION

The first 6 months of pharmacological or psychosocial treatment is associated with reduced heroin and crack cocaine use, but the effectiveness of pharmacological treatment is less pronounced for users of both drugs. New strategies are needed to treat individuals with combined heroin and crack cocaine addiction.

FUNDING

National Treatment Agency for Substance Misuse.

Development of the Treatment Outcomes Profile

AIM

To develop the Treatment Outcomes Profile (TOP), a new instrument for monitoring substance misuse treatment.

DESIGN

Prospective cohort, psychometric evaluation with 7-day retest and 1-month follow-up to assess inter-rater reliability, concurrent, discriminant and construct validity, and change sensitivity.

PARTICIPANTS

A sample of 1021 service users, aged 16-62 years. Recruitment from 63 treatment agencies in England, collectively providing opioid substitution treatment, psychosocial interventions, in-patient detoxification and residential rehabilitation.

MEASUREMENTS

Thirty-eight frequency, rating scale and period prevalence measures, with 28-day recall, across substance use, health, crime and social functioning domains, administered as personal interview by 163 treatment keyworkers.

FINDINGS

Twenty outcome measures met inter-rater reliability criteria: days used alcohol, opioids, crack cocaine, cocaine powder, amphetamines, cannabis and one other named substance; days injected and period prevalence of direct or indirect needle/syringe sharing; subjective rating of physical and psychological health; days committed shop theft and drug selling, period prevalence of vehicle, property, fraud/forgery and assault/violence offences; rating of quality of life; days worked and attended for education/training; and period prevalence of acute housing problems and risk of eviction. Intraclass correlation coefficients for scale measures and Cohen's kappa for dichotomous measures reached or exceeded 0.75 and 0.61, respectively. There were satisfactory validity assessments and change sensitivity of scale items judged by effect size and smallest detectable difference. The TOP clinical tool contains an additional 10 items for individual treatment planning and review.

CONCLUSIONS

The TOP is a reliable and valid 20-item instrument for treatment outcomes monitoring.

Rapid approach responses to alcohol cues in heavy drinkers

Incentive-motivational models of addiction predict that alcohol cues should elicit approach behaviours in heavy drinkers. In this study we compared heavy and light social drinkers' response latencies when required to make approach or avoidance responses to alcohol pictures. Participants completed a stimulus-response compatibility (SRC) task, which requires participants to move a manikin towards or away from alcohol-related and matched control pictures, together with self-report measures of alcohol consumption and craving. Results demonstrated that heavy drinkers, but not light drinkers, were faster to approach than avoid alcohol pictures on the SRC task. The bias to approach alcohol pictures was also associated with alcohol craving.

Experimental manipulation of attentional biases in heavy drinkers: do the effects generalise?

RATIONALE

In heavy drinkers, training attention towards alcohol cues increases alcohol craving, but it is not clear if effects of 'attentional training' generalise to novel stimuli and measurement procedures.

OBJECTIVES

We investigated possible generalisation of attentional training to novel alcohol cues and other methods of measuring cognitive bias.

MATERIALS AND METHODS

A modified visual probe task was used to train participants to direct their attention either towards ('attend alcohol' group) or away from ('avoid alcohol' group) alcohol cues; attentional bias was not manipulated in a control group (total N = 60). After attentional training, we measured cognitive bias (using visual probe, modified Stroop, flicker-induced change blindness and stimulus-response compatibility tasks), alcohol craving and alcohol consumption.

RESULTS

Attentional bias for alcohol cues increased in the 'attend alcohol' group, and this effect generalised to novel stimuli, but not to other cognitive bias tasks. In the 'avoid alcohol' group, attentional bias was reduced for the stimuli that were used during attentional training, but these effects did not generalise to different stimuli or cognitive bias tasks. Alcohol craving increased among participants in the 'attend alcohol' group, but only among participants who were aware of the experimental contingencies during attentional training. There were no group differences in alcohol consumption.

CONCLUSIONS

The effects of attentional training show limited generalisation to different alcohol cues and methods of measuring cognitive bias. Experimentally increased attentional bias seems to increase subjective craving, but only among participants who are aware of the experimental contingencies that were in place during attentional training.

Selective processing of cannabis cues in regular cannabis users

Recent studies indicate that the regular use of certain drugs, such as tobacco and alcohol, is associated with biases in the processing of drug-related cues, as those cues grab attention, elicit approach and are perceived as pleasant. This study investigated whether regular cannabis users exhibit comparable cognitive biases for cannabis-related pictorial cues. Twenty-three regular cannabis users and 23 non-user controls completed a series of tasks including a visual probe task with concurrent eye movement monitoring (to measure attentional bias), a stimulus-response compatibility task (to measure implicit approach bias) and a valence rating task (to measure the perceived pleasantness of cannabis cues). Results indicated that, relative to non-users, regular cannabis users had biases to maintain their gaze on cannabis cues, to make faster approach responses towards cannabis cues, and to rate cannabis cues as pleasant. Results are generally consistent with previous findings from tobacco smokers and heavy drinkers, and the implications for incentive-motivational theories of addiction are discussed.

The relationship of in vivo central CB1 receptor occupancy to changes in cortical monoamine release and feeding elicited by CB1 receptor antagonists in rats

RATIONALE

Cannabinoid type 1 (CB(1)) receptor antagonists are reportedly effective in reducing food intake both preclinically and clinically. This may be due in part to their effects on monoamine release in the brain. The level of central CB(1) receptor occupancy underlying these neurobiological effects is unclear.

OBJECTIVES

We explored the relationship between in vivo CB(1) receptor occupancy in the frontal cortex and changes in both monoamine release in the medial prefrontal cortex (mPFC) and feeding behavior in rats in response to two orally administered CB(1) receptor antagonists presently in clinical trials, SR141716A (rimonabant) and SLV319.

METHODS

CB(1) receptor occupancy was measured using [(3)H] SR141716A, and these occupancies were related to potencies to mediate increases in dopamine (DA) and norepinephrine (NE) release measured with microdialysis and decreases in consumption of a highly palatable diet (HP).

RESULTS

High receptor occupancy levels (>65%) were required to detect increases in monoamine release that were achieved with 3 and 10 mg/kg of SR141716A and 10 mg/kg of SLV319 for DA and 10 mg/kg of SR141716A for NE. Decreases in HP consumption were seen at occupancies higher than 65% for SR141716A that were achieved with 3 and 10 mg/kg. In contrast, decreases in HP consumption were seen at relatively low CB(1) receptor occupancies (11%) for SLV319.

CONCLUSIONS

The occupancy method described here is an effective tool for interrelating central CB(1) receptor occupancy with neurobiological actions of CB(1) receptor antagonists and for furthering our understanding of the role of CB(1) receptors in central nervous system physiology and pathology.

Experimental manipulation of attentional bias increases the motivation to drink alcohol

RATIONALE

Attentional bias for alcohol-related cues is associated with the motivation to drink alcohol, possibly because attentional bias increases craving.

OBJECTIVES

We examined whether an experimentally induced attentional bias would influence subjective and behavioural indices of the motivation to drink.

METHODS

Heavy social drinkers (N=40) completed an attentional training procedure, in which half of the participants were trained to direct their attention towards alcohol-related cues ('attend alcohol'), and half of the participants were trained to direct their attention away from alcohol-related cues ('avoid alcohol'). After attentional training, participants rated their urge to drink alcohol, and the amount of beer consumed during a taste test was measured.

RESULTS

The attentional training procedure produced significant changes in attentional bias in the predicted direction in both experimental groups. Attentional training produced an increase in the urge to drink alcohol in the attend alcohol group, and the attend alcohol group consumed more beer than the avoid alcohol group during the taste test.

CONCLUSIONS

These results suggest that a potentiated attentional bias for alcohol-related cues can increase the motivation to drink alcohol. Theoretical and clinical implications are discussed.

Reduced levels of amyloid beta-peptide antibody in Alzheimer disease

OBJECTIVE

To investigate whether it was possible to detect the presence and different levels of naturally occurring anti-beta-amyloid (Abeta) antibodies in the CSF of patients with AD and age-matched controls by employing a sensitive ELISA.

BACKGROUND

Immunization with preaggregated amyloid beta-peptide (Abeta(1-42)) and administration of antibodies against Abeta into amyloid precursor protein APP(V717F)- transgenic mice (an animal model of AD) have recently been reported to dramatically reduce amyloid plaque deposition, neuritic dystrophy, and astrogliosis, most likely by enhancing Abeta clearance from brain.

METHODS

A sensitive ELISA was performed to detect levels of naturally occurring anti-Abeta antibodies in the CSF of patients with AD and age-matched controls. Additionally, an immunoprecipitation assay was performed to confirm that naturally occurring anti-Abeta antibodies also exist in the human blood.

RESULT

- Naturally occurring antibodies directed against Abeta were found in the CSF and plasma of patients with AD and healthy control subjects. Moreover, CSF anti-Abeta antibody titers are significantly lower in patients with AD compared with healthy control subjects.

CONCLUSION

Naturally occurring antibodies directed against Abeta exist in human CSF and plasma. The CSF anti-Abeta antibody titers may be helpful in better understanding the effects of future immunologic therapies for AD.

Alpha2 macroglobulin and the risk of Alzheimer's disease

BACKGROUND

alpha2 Macroglobulin is a panproteinase inhibitor that is found immunohistochemically in neuritic plaques, a requisite neuropathologic feature of AD. Recently, a pentanucleotide deletion near the 5' end of the "bait region" of the alpha2 macroglobulin (A2M) gene was reported to be associated with AD in a large cohort of sibpairs, in which the mutation conferred a similar odds ratio with AD as the APOE-epsilon4 allele for carriers of at least one copy of the A2M gene (Mantel-Haenszel odds ratio, 3.56).

METHODS

We studied three independent association samples of AD patients (n = 309) with an age range of 50 to 94 years and representative controls (n = 281) to characterize the allele frequency of the pentanucleotide deletion in this cohort. We detected the mutation near the 5' splice site of exon 18 using standard PCR and restriction fragment length polymorphism methods. The results were adjusted for age, gender, education, and APOE polymorphism.

RESULTS

We found that the A2M gene polymorphism conferred an increased risk for AD, with an estimated Mantel-Haenszel ratio of 1.5 (95% CI 1.1 to 2.2; p = 0.025). There was no age- or gender-dependent increase in A2M gene allele frequencies in AD patients compared with controls. The combined sample showed the expected association between AD and APOE-epsilon 4. In one of our three samples there was an interaction between the A2M and APOE-epsilon4 genes, but the other two samples showed no interaction between the two risk factors.

CONCLUSIONS

Our data support an association between the A2M gene and AD. This association is less pronounced, however, in our cohort than in the previously reported sample of sibpairs.

Parental willingness to enter a child in a controlled vaccine trial

OBJECTIVE

To determine the reasons that motivate parents to enrol or not enrol their child in a randomized, controlled vaccine trial.

DESIGN

Cross-sectional survey.

SETTING

Offices of primary care physicians in Dartmouth, Nova Scotia, and Montreal, Quebec.

PARTICIPANTS

At the 2 sites, parents of 2-month-old infants at their first immunization visit who had decided to enrol (221) or not enrol (208) their child in 2 randomized pertussis vaccine trials.

OUTCOME MEASURES

Rates of enrolment in vaccine trials; attitudes about medical research; sources of information about pertussis.

RESULTS

Enrolment rates were 68% and 43% at the 2 sites. All parents agreed to answer questions about their decision to enrol or not enrol their child. The most common concerns resulting in nonenrolment were extra immunization 54% (26/48) and blood procurement 42% (20/48). Parents who did enrol their children were motivated to participate by the desire to contribute to medical knowledge (77% [170/221]), the desire to help others (48% [106/221]) and by the participation of their family physician (54% [120/221]). The enrollees' major sources of information about pertussis was health professionals or study personnel rather than the media.

CONCLUSIONS

Altruistic reasons motivate parents' decision to enrol a child in a randomized, controlled vaccine trial. Nonparticipating parents seem most concerned about painful procedures in the study. Parents' decisions regarding participation do not appear to be affected by adverse media attention regarding the purported adverse sequelae of pertussis vaccines.

Safety and immunogenicity of two acellular pertussis vaccines with different pertussis toxoid and filamentous hemagglutinin content in infants 2-6 months old

The optimal composition and antigen content of acellular pertussis vaccines is not known. Two vaccines with different quantities of pertussis toxoid (10 and 20 micrograms) and filamentous hemagglutinin (5 and 20 micrograms) and identical 69 kD protein (3 micrograms) and fimbriae 2 and 3 (5 micrograms) combined with diphtheria and tetanus toxoids were compared in a randomized, double-blind study in 2,050 infants undergoing their primary immunization series at 8 centers in the US and Canada. A 6:1 increased antigen to lower antigen allocation was used; 96% of infants received 3 doses and completed the study. A 'clinically significant' local reaction was reported in 3-6% of participants after each dose. Erythema was the most common reaction occurring in 3-5% of infants after the second or third dose. A clinically significant systemic adverse reaction was reported in 28-34% of vaccinees (or vaccinated children) after each dose; fever (7-18%) and fussiness (12-17%) were most common. There were no differences in adverse events between the 2 vaccine formulations. Antibody responses were measured in 292 infants at 1 center. At 7 months, geometric mean anti-filamentous hemagglutinin antibody titers were higher in recipients of the higher antigen content vaccine (p < 0.001) whereas recipients of the lower antigen content formulation had higher anti-fimbriae antibody (p < 0.001) and agglutinin titers (p < 0.05). No differences were detected in anti-pertussis toxin or other antibody responses between the formulations. We conclude that increasing the antigen content of the acellular pertussis vaccine had a variable effect on antibody response but was not associated with increased adverse reactions.

Clinical course of cognitive dysfunction in systemic lupus erythematosus

OBJECTIVE

To prospectively evaluate changes in cognitive function in a cohort of unselected patients with systemic lupus erythematosus (SLE) and controls over a 12 month period.

METHODS

Seventy female patients with SLE, 25 patients with rheumatoid arthritis (RA) and 23 healthy subjects (age and sex matched) were evaluated using the Wechsler Adult Intelligence Scale-Revised (WAIS-R), the Wechsler Memory Scale-Revised (WMS-R), the California Verbal Learning Test (CVLT) and the National Adult Reading Test-Revised to identify impairment in 8 areas of cognitive function. Cumulative disease manifestations and current medications were documented, and disease activity was expressed using the SLE disease activity index (SLEDAI). Decision rules were determined for overall cognitive impairment.

RESULTS

At baseline, 21% (15/70) of patients with SLE were impaired compared to 4% (1/25) of patients with RA and 4% (1/23) of healthy subjects (p = 0.042). After a mean interval of 12.8 months (range: 11-17) 84% (59/70) of patients with SLE, 44% (11/25) of patients with RA and 80% (17/23) of healthy subjects were reassessed. This included all subjects who were impaired at the initial assessment. Using the same decision rules as at baseline, 12% (7/59) of patients with SLE were impaired at followup compared to none of the patients with RA and healthy subjects. Over the period of study cognitive impairment persisted in 3 patients with SLE, resolved in 12 and evolved in 4 others. There was no apparent association between changes in cognitive function and concurrent changes in generalized disease activity, overt neuropsychiatric disease or corticosteroid medication.

CONCLUSION

Our results suggest that cognitive dysfunction in patients with SLE is evanescent, does not necessarily lead to irreversible neurologic compromise and changes independently of other clinical variables.

Brain reactive autoantibodies and cognitive impairment in systemic lupus erythematosus

Nervous system involvement in SLE encompasses a wide array of clinical manifestations which may reflect multiple etiologic factors including autoantibodies to nervous tissue antigens. The aim of the present study was to examine the association between autoantibodies to a wide range of brain antigens and cognitive abnormalities in an unselected population of 70 SLE patients. Using a battery of standardized neuropsychological tests, cognitive impairment was identified in 15/70 (21%) SLE patients compared with 1/25 (4%) patients with rheumatoid arthritis and 1/23 (4%) healthy subjects (P = 0.04). Integral membrane proteins were isolated from dissociated brain cells by temperature-induced phase separation with Triton X-114. Synaptosomes were isolated by differential centrifugation and membrane enriched fractions were prepared by lectin affinity chromatography. Western blotting identified IgG reactivity to a wide range of proteins (MW 22-52 K) in SLE patients. The proteins identified were distinct from well-characterized intracellular antigens including ribosomal P proteins. There was no significant difference in the prevalence of anti-brain antibodies between SLE patients who were cognitively impaired and those who were not impaired. Furthermore, there was no association between the presence of autoantibodies and subsets of cognitive dysfunction. These results suggest that circulating autoantibodies to brain antigens are not responsible for the abnormalities in cognitive function in SLE patients.

Patterns of cognitive impairment in patients with systemic lupus erythematosus

This study examined neuropsychological test performance in a representative sample of 70 female patients with SLE. The influence of current or past clinically overt central nervous system involvement, use of corticosteroid medications and overall disease activity were evaluated. The results suggest two distinct patterns of cognitive dysfunction. Impaired delayed recognition memory was associated with past or current nervous system involvement, suggesting the presence of a residual neurologic deficit. Increased disease activity was associated with impaired immediate memory and concentration which may represent transient and diffuse central nervous system effects. Although corticosteroid use was associated with poor word list recall, group differences were not statistically significant when disease activity was considered as a covariate in the analysis. Follow-up studies are required to determine if these abnormalities persist or fluctuate with changes in disease activity and concurrent medications.

Cognitive impairment and autoantibodies in systemic lupus erythematosus

Nervous system involvement in systemic lupus erythematosus (SLE) includes a wide array of manifestations some of which have been associated with specific autoantibodies. These include reactivity to surface neuronal and lymphocyte antigens, ribosomal P and cardiolipin. The aim of the present study was to examine the association between cognitive abnormalities and these autoantibodies in an unselected female population of SLE patients. Using a battery of standardized neuropsychological tests, cognitive impairment was identified in 15/70 (21%) SLE patients compared to 1/25 (4%) patients with rheumatoid arthritis and 1/23 (4%) healthy subjects (P = 0.04). Circulating antineuronal antibodies were measured by indirect immunofluorescence using human neuroblastoma cell lines IMR-6 and SK-N-SH. Lymphocytotoxic antibodies were measured by microcytotoxicity. Antibodies to ribosomal P and cardiolipin were measured by ELISA. Antineuronal antibodies were detected in 34%, lymphocytotoxic antibodies in 47%, anti-P antibodies in 17% and anticardiolipin antibodies in 24% of patients. In the cognitively impaired and unimpaired SLE patients there was no significant difference in the prevalence of antineuronal antibodies (33 vs 35%), lymphocytotoxic antibodies (40 vs 50%), anti-P antibodies (20 vs 17%) or anticardiolipin antibodies (7 vs 29%). The titre and isotype of autoantibodies were also similar in both groups. These results suggest that autoantibodies which have previously been associated with nervous system manifestations of SLE are not likely to be directly involved in the pathogenesis of cognitive dysfunction.