Article

Exposure to opioid maintenance treatment reduces long-term mortality

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Abstract

To (i) examine the predictors of mortality in a randomized study of methadone versus buprenorphine maintenance treatment; (ii) compare the survival experience of the randomized subject groups; and (iii) describe the causes of death. Ten-year longitudinal follow-up of mortality among participants in a randomized trial of methadone versus buprenorphine maintenance treatment. Recruitment through three clinics for a randomized trial of buprenorphine versus methadone maintenance. A total of 405 heroin-dependent (DSM-IV) participants aged 18 years and above who consented to participate in original study. Baseline data from original randomized study; dates and causes of death through data linkage with Births, Deaths and Marriages registries; and longitudinal treatment exposure via State health departments. Predictors of mortality examined through survival analysis. There was an overall mortality rate of 8.84 deaths per 1000 person-years of follow-up and causes of death were comparable with the literature. Increased exposure to episodes of opioid treatment longer than 7 days reduced the risk of mortality; there was no differential mortality among methadone versus buprenorphine participants. More dependent, heavier users of heroin at baseline had a lower risk of death, and also higher exposure to opioid treatment. Older participants randomized to buprenorphine treatment had significantly improved survival. Aboriginal or Torres Strait Islander participants had a higher risk of death. Increased exposure to opioid maintenance treatment reduces the risk of death in opioid-dependent people. There was no differential reduction between buprenorphine and methadone. Previous studies suggesting differential effects may have been affected by biases in patient selection.

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... Schools, local shops, community centres, and places of worship may also double as ideal points of contact with geographically dispersed communities. (Brugal, 2005;Connock et al., 2007;Darke, Williamson, Ross, & Teesson, 2005;Degenhardt et al., 2011Degenhardt et al., , 2014Gibson et al., 2008;Kimber et al., 2010;Kinner et al., 2012;Milloy et al., 2008;Soyka, Apelt, Lieb, & Wittchen, 2006); 4 (Brugal et al., 2002;Darke & Hall, 2003;Degenhardt et al., 2011); 5 (Albert et al., 2011;El-Aneed et al., 2009;Feldman, Williams, Coates, & Knox, 2011;Mello et al., 2013;Simeone & Holland, 2006;Strang et al., 2012); 6 (Auriacombe, Franques, & Tignol, 2001;Bell, Butler, Lawrance, Batey, & Salmelainen, 2009;Gibson et al., 2008;Kakko, Svanbord, Kreek, & Hellig, 2003;Luty, O'Gara & Sessay, 2005;Soyka et al., 2006;Umbricht, Huestis, Cone, & Preston, 2004); 7 (Albert et al., 2011;Bennett et al., 2011;Clark, Wilder, & Winstanley, 2014;United Nations Commission on Narcotic Drugs, 2012;Eggertson, 2013;Enteen et al., 2010;Green, Heimer & Grau, 2008;Kim et al., 2009;Maxwell et al., 2006;Mello et al., 2013;Piper et al., 2008;Walley et al., 2013;Wheeler et al., 2012 (Fudula et al., 2003); 10 (Havinga, van der Velden, de Gee, & van der Poel, 2014;Moore, 2004;Rhodes, 2002);11 (Dhalla et al., 2011;Jovey et al., 2003;Krebs, Ramsey, Miloshoff, & Bair, 2011); 12 (Hulse et al., 2005); 13 (Hedrich, Kerr, & Dubois-Arber, 2010;Marshall, Milloy, Wood, Montaner, & Kerr., 2011;Poschade, Hoger, & Schnitzler, 2003); 14 (Dhalla & Laupacis, 2008;Dhalla et al., 2011;Goldacre, Carrol, & t Hall, 2013;Persaud, 2013;Spielmans & Parry, 2010;Van Zee, 2009) ...
... Schools, local shops, community centres, and places of worship may also double as ideal points of contact with geographically dispersed communities. (Brugal, 2005;Connock et al., 2007;Darke, Williamson, Ross, & Teesson, 2005;Degenhardt et al., 2011Degenhardt et al., , 2014Gibson et al., 2008;Kimber et al., 2010;Kinner et al., 2012;Milloy et al., 2008;Soyka, Apelt, Lieb, & Wittchen, 2006); 4 (Brugal et al., 2002;Darke & Hall, 2003;Degenhardt et al., 2011); 5 (Albert et al., 2011;El-Aneed et al., 2009;Feldman, Williams, Coates, & Knox, 2011;Mello et al., 2013;Simeone & Holland, 2006;Strang et al., 2012); 6 (Auriacombe, Franques, & Tignol, 2001;Bell, Butler, Lawrance, Batey, & Salmelainen, 2009;Gibson et al., 2008;Kakko, Svanbord, Kreek, & Hellig, 2003;Luty, O'Gara & Sessay, 2005;Soyka et al., 2006;Umbricht, Huestis, Cone, & Preston, 2004); 7 (Albert et al., 2011;Bennett et al., 2011;Clark, Wilder, & Winstanley, 2014;United Nations Commission on Narcotic Drugs, 2012;Eggertson, 2013;Enteen et al., 2010;Green, Heimer & Grau, 2008;Kim et al., 2009;Maxwell et al., 2006;Mello et al., 2013;Piper et al., 2008;Walley et al., 2013;Wheeler et al., 2012 (Fudula et al., 2003); 10 (Havinga, van der Velden, de Gee, & van der Poel, 2014;Moore, 2004;Rhodes, 2002);11 (Dhalla et al., 2011;Jovey et al., 2003;Krebs, Ramsey, Miloshoff, & Bair, 2011); 12 (Hulse et al., 2005); 13 (Hedrich, Kerr, & Dubois-Arber, 2010;Marshall, Milloy, Wood, Montaner, & Kerr., 2011;Poschade, Hoger, & Schnitzler, 2003); 14 (Dhalla & Laupacis, 2008;Dhalla et al., 2011;Goldacre, Carrol, & t Hall, 2013;Persaud, 2013;Spielmans & Parry, 2010;Van Zee, 2009) ...
Technical Report
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The present document is intended for Canadian health care and public health practitioners within health authorities, not-for-profit organizations, pharmacists, clinicians, and any other peers and professionals who are interested in establishing a naloxone distribution program to address opioid overdose in their communities. It provides a basic outline of how naloxone works, ways a naloxone program can be set up and the forms of collaboration it may take, ideas for the content to include in any associated risk-reduction training, and considerations to keep in mind to assure a comprehensive and effective overdose prevention program adapted to the particular context. Created in the context of an internship with the National Collaborating Centre for Healthy Public Policy in Montréal, QC (available in French at https://www.ccnpps.ca/docs/2016_OBNL_NGO_GuidePratique_Fr.pdf)
... While the benefits of MMT adherence are well established for a number of health and justice outcomes, including reduced health care costs [28], the role of MMT adherence in mortality among offenders is less clear. A number of observational studies in Europe and Australia have indicated that adherence to methadone reduces the risk of death during treatment compared with periods of nontreatment [29][30][31][32][33] in general opiate-dependent populations. In these studies, treatment effects of methadone are strongest for drug-related deaths [31] and among subpopulations of MMT users with infectious diseases (e.g., by potentiating adherence to antiretroviral treatments [ARTs]) [34]. ...
... In these studies, treatment effects of methadone are strongest for drug-related deaths [31] and among subpopulations of MMT users with infectious diseases (e.g., by potentiating adherence to antiretroviral treatments [ARTs]) [34]. However, these studies are not specific to offenders (in or out of custody) and are drawn from relatively small samples sizes [30,31,35], with maximum follow-up periods of 4 to 7 years [29,33,36]. Among studies that do focus on MMT among offenders, most concentrate on mortality in the initial postrelease period [16,37] or during custody [38,39]. ...
Article
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Background Individuals with criminal histories have high rates of opioid dependence and mortality. Excess mortality is largely attributable to overdose deaths. Methadone maintenance treatment (MMT) is one of the best evidence-based opioid substitution treatments (OSTs), but there is uncertainty about whether methadone treatment reduces the risk of mortality among convicted offenders over extended follow-up periods. The objective of this study was to investigate the association between adherence to MMT and overdose fatality as well as other causes of mortality. Methods and findings We conducted a retrospective cohort study involving linked population-level administrative data among individuals in British Columbia (BC), Canada with a history of conviction and who filled a methadone prescription between January 1, 1998 and March 31, 2015. Participants were followed from the date of first-dispensed methadone prescription until censoring (date of death or March 31, 2015). Methadone was divided into medicated (methadone was dispensed) and nonmedicated (methadone was not dispensed) periods and analysed as a time-varying exposure. Hazard ratios (HRs) with 95% CIs were estimated using multivariable Cox regression to examine mortality during the study period. All-cause and cause-specific mortality rates were compared during medicated and nonmedicated methadone periods. Participants (n = 14,530) had a mean age of 34.5 years, were 71.4% male, and had a median follow-up of 6.9 years. A total of 1,275 participants died during the observation period. The overall all-cause mortality rate was 11.2 per 1,000 person-years (PYs). Participants were significantly less likely to die from both nonexternal (adjusted HR [AHR] 0.27 [95% CI 0.23–0.33]) and external (AHR 0.41 [95% CI 0.33–0.51]) causes during medicated periods, independent of sociodemographic, criminological, and health-related factors. Death due to infectious diseases was 5 times lower (AHR 0.20 [95% CI 0.13–0.30]), and accidental poisoning (overdose) deaths were nearly 3 times lower (AHR 0.39 [95% CI 0.30–0.50]) during medicated periods. A competing risk regression demonstrated a similar pattern of results. The use of a Canadian offender population may limit generalizability of results. Furthermore, our observation period represents community-based methadone prescribing and may omit prescriptions administered during hospital separations. Therefore, the magnitude of the protective effects of methadone from nonexternal causes of death should be interpreted with caution. Conclusions Adherence to methadone was associated with significantly lower rates of death in a population-level cohort of Canadian convicted offenders. Achieving higher rates of adherence may reduce overdose deaths and other causes of mortality among offenders and similarly marginalized populations. Our findings warrant examination in other study centres in response to the crisis of opiate-involved deaths.
... 3,5 Treatment with MOUDs is essential to reduce mortality and risk of overdose, as well as to improve retention in treatment programs. 5,6 Buprenorphine is most commonly utilized due to a favorable safety profile as compared to other MOUDs and lower overdose risk from partial vs full agonism, as well as coformulations with naloxone that reduce risk of use by injection. Additionally, MOUDs outside of buprenorphine have significant barriers to initiation. ...
Article
Disclaimer In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose Extended-release (ER) monthly injectable buprenorphine offers an alternative to daily sublingual (SL) dosing for treatment of opioid use disorder (OUD) that may be attractive to several patient populations, including those with barriers to adherence and the frequent follow-up that are necessary for traditional SL buprenorphine. Despite the potential benefits of ER-buprenorphine, there are significant barriers to healthcare provider adoption that may prevent utilization in the populations that would benefit. Summary Our health system began providing clinic-administered ER-buprenorphine as treatment for OUD in May 2018 at a single clinic. Expansion was limited due to difficulties with delayed and inaccurate medication delivery and heavy administrative burden. To facilitate uptake of ER-buprenorphine for patients who could benefit, our integrated health-system specialty pharmacy (HSSP) assumed responsibility for medication distribution and administrative management beginning in October 2019. The HSSP provided accurate medication delivery, alleviated administrative burdens of benefits investigation and Risk Evaluation and Mitigation Strategy compliance, and decreased medication wastage by implementing a medication return process. Subsequently, ER-buprenorphine services were expanded to 4 additional sites, allowing 244 more patients to receive treatment. Conclusion HSSP support can provide significant benefit to patients and the health system through coordinating ER-buprenorphine dispensing and delivery.
... Evidence of the effectiveness of SUD treatments shows that medications, such as buprenorphine and methadone, were found to significantly decrease return to use rates compared to behavioral therapy alone [4]. In addition, patients who were maintained on medication treatment for OUD for longer than one week had a 28% reduction in their risk for opioid-related death [5]. This highlights the importance of health care practitioners being informed about the most effective interventions for people with SUDs, including medication for OUD. ...
Article
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Background: Access to and quality of care for Substance Use Disorders (SUDs) remain a major public health issue. Stigma associated with SUDs contributes to the gap between the number of patients who need treatment and the much smaller fraction that receive it. Healthcare professional students are future care providers; an opportunity exists to characterize their collective perspectives on patients with SUDs and how that informs the care they provide. Methods: Healthcare professional students participated in online, semi-structured focus group (FGs) between March and April 2021. The FGs were conducted until thematic saturation was achieved. All verbatim transcripts were analyzed applying Thematic Analysis using Dedoose® qualitative software. Inductive codes were grouped into categories based on similarities that facilitated the emergence of themes. Results: Thematic Analysis revealed one theme (1) Decreasing stigma among healthcare professionals by viewing substance use disorder as a disease; and two sub-themes: Subtheme 1a: Relating with the patients, "It could be me…"; Subtheme 1b: Interactions with patients, "We just don't know exactly how to counsel these patients…" These themes describe how future healthcare professionals might perceive and approach patients with SUDs and highlight the importance of SUD training in the curriculum. Conclusion: Medical and pharmacy students are uniquely positioned to apply critical thinking from their didactic training to their real-world clinical experiences, and their collective perspectives inform gaps in training and opportunities to develop best practices for SUD care. An opportunity exists to leverage these findings in order to train future healthcare professionals to ensure access to and quality of SUD care.
... 8 These medications decrease patients' risk of contracting infectious diseases such as human immunodeficiency virus, decrease their risk of suffering an overdose, and decrease their overall healthcare utilization. 4,[9][10][11] Drugs commonly used in MAT include methadone, a full μ-opioid receptor agonist; buprenorphine, a partial μ-opioid receptor agonist; and naltrexone, a μ-opioid receptor antagonist. 12 Due to their differing pharmacodynamics, each of these drugs has strengths and weaknesses in terms of initiation and induction, the logistics of distribution, potential for abuse, and risk of overdose and withdrawal. ...
Article
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Introduction: Recent studies from urban academic centers have shown the promise of emergency physician-initiated buprenorphine for improving outcomes in opioid use disorder (OUD) patients. We investigated whether emergency physician-initiated buprenorphine in a rural, community setting decreases subsequent healthcare utilization for OUD patients. Methods: We performed a retrospective chart review of patients presenting to a community hospital emergency department (ED) who received a prescription for buprenorphine from June 15, 2018-June 15, 2019. Demographic and opioid-related International Classification of Diseases, 10th Revision, (ICD-10) codes were documented and used to create a case-matched control cohort of demographically matched patients who presented in a similar time frame with similar ICD-10 codes but did not receive buprenorphine. We recorded 12-month rates of ED visits, all-cause hospitalizations, and opioid overdoses. Differences in event occurrences between groups were assessed with Poisson regression. Results: Overall 117 patients were included in the study: 59 who received buprenorphine vs 58 controls. The groups were well matched, both roughly 90% White and 60% male, with an average age of 33.4 years for both groups. Controls had a median two ED visits (range 0-33), median 0.5 hospitalizations (range 0-8), and 0 overdoses (range 0-3), vs median one ED visit (range 0-8), median 0 hospitalizations (range 0-4), and median 0 overdoses (range 0-3) in the treatment group. The incidence rate ratio (IRR) for counts of ED visits was 0.61, 95% confidence interval (CI), 0.49, 0.75, favoring medication-assisted treatment (MAT). For hospitalizations, IRR was 0.34, 95% CI, 0.22, 0.52 favoring MAT, and for overdoses was 1.04, 95% CI, 0.53, 2.07. Conclusion: Initiation of buprenorphine by ED providers was associated with lower 12-month ED visit and all-cause hospitalization rates with comparable overdose rates compared to controls. These findings show the ED's potential as an initiation point for medication-assisted treatment in OUD patients.
... buprenorphine/buprenorphine-naloxone (BUP-NX) or naltrexone/ extended-release naltrexone (XR-NTX)) has been a mainstay in OUD treatment (Hulse et al., 2009;Lee et al., 2018;Nunes et al., 2015;Renner et al., 2018;Ward et al., 1999). Numerous studies and meta-analyses have concluded that BUP-NX and XR-NTX improve treatment retention, decrease illicit opioid use (Hulse et al., 2009;Krupitsky et al., 2011;Shulman et al., 2019), and reduce mortality in people with opioid use disorder (Gibson et al., 2008;Larochelle et al., 2018). However, little is known about how polysubstance use impacts the efficacy of MOUD (Lin et al., 2021). ...
Article
Objectives Our objectives were to examine the impact of methamphetamine use on opioid use disorder (OUD) treatment retention in patients prescribed either buprenorphine/buprenorphine-naloxone (BUP-NX) or naltrexone/extended-release naltrexone (XR-NTX), while also exploring the role of other risk factors that may modify the impact of methamphetamine use. Methods We conducted an exploratory retrospective study examining OUD treatment retention in 127 patients in Ohio (USA). Patients were prescribed either BUP-NX or naltrexone/XR-NTX. Cox proportional hazard regression was used to compare time to dropout of treatment between patients positive and negative on screening for methamphetamines at intake, estimate the association between other risk factors and time to dropout, and test interactions between risk factors and methamphetamine status. Results Among patients prescribed naltrexone/XR-NTX, those positive for methamphetamines had almost three times the risk of treatment dropout (AHR = 2.89, 95% CI =1.11, 7.07), significantly greater (interaction p = .039) than the methamphetamine effect among those prescribed BUP-NX (AHR = 0.94, 95% CI = 0.51, 1.65). Early in treatment, being prescribed BUP-NX was strongly associated with a greater risk of treatment dropout (at baseline: AHR = 2.90, 95% CI = 1.33, 7.15), regardless of baseline methamphetamine use status. However, this effect decreased with time and shifted to greater risk of dropout among those prescribed naltrexone/XR-NTX (non-proportional hazard; interaction with time AHR = 0.66, 95% CI = 0.49, 0.86), with the shift occurring sooner among those positive for methamphetamine at baseline. Conclusions Additional support should be provided to patients who use methamphetamines prior to starting OUD treatment.
... Providers who lack an interest in working with patients who have an addiction (Molfenter, Sherbeck, Zehner, Quanbeck, et al., 2015a, 2015b or face extensive time and staffing constraints (Molfenter, Sherbeck, Zehner, & Starr, 2015) may contribute to patients discontinuing treatment (Gryczynski et al., 2014). About half of patients drop out of treatment in the first few months (Gryczynski et al., 2014;Hser et al., 2014), making them susceptible to a higher incidence of death from overdose (Caplehorn et al., 1994;Clausen et al., 2009;Degenhardt et al., 2011;Gibson et al., 2008;Kornør et al., 2007). ...
Article
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The expansion of access to medication-assisted treatment by states and the federal government serves as one important tool for tackling the opioid crisis. Achieving this goal requires increasing the number of medical professionals who hold DATA Waiver 2000 waived status, which allows providers to prescribe the medication utilized by treatment programs. Waived providers are scarce throughout rural America, placing a potentially large burden on those who do hold a waiver. This paper uses data gathered through qualitative interviews with healthcare workers and patients at MAT clinics in Montana to understand how the relationship between rural healthcare workers and MAT patients contributes to burnout and potential staff turnover in a rural setting. Patients defined quality care via the patient-staff relationship, including expectations of personal support and viewing staff availability as a requirement for their recovery. Healthcare workers, in contrast, refer to their availability to patients as overwhelming and necessary both during and after business hours. These findings illuminate the need to continue expanding MAT access in rural communities, especially in non-specialty care settings including primary care offices and Federally Qualified Health Centers.
... 3 Studies suggest that buprenorphine-and medications for opioid use disorder (MOUD) more broadly-results in a marked reduction in mortality. 4,5 Buprenorphine has some benefits over its primary alternative MOUD, methadone, due to its flexibility in prescribing 6 and its respiratory and cardiovascular safety profile. 3 It is commonly prescribed as a combination product with naloxone, which is intended to deter recreational misuse (by IV injection) of the medication. ...
Article
Opioid use disorder has affected many lives across the US. Medications for opioid use disorder (MOUD), including buprenorphine, have been shown to decrease mortality in this patient population. Here we present a case of a 32-year-old woman on buprenorphine/naloxone undergoing multiple surgical operations, whose course included buprenorphine discontinuation, methadone initiation, and buprenorphine re-induction using a novel “microdosing” approach. This report includes a presentation of the case and a discussion of the clinical decision making and relevant literature to give hospitalbased providers a perspective on management of peri-operative patients on MOUD.
... The group with psychiatric morbidity did not have prescriptions for methadone. These findings are particularly worrying as treatment for DUD is an intervention known to reduce the risk of premature death [28] and the combined use of prescribed and nonprescribed methadone and benzodiazepines may contribute to the increased mortality in this group [29]. ...
Article
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Purpose: To estimate the prevalence of psychiatric morbidity and dual diagnosis in a population of decedents with positive drug toxicology and evaluate changes over time between 2001-2002 and 2011-2012. Materials and methods: A total of 520 autopsied drug users with positive toxicology were included in the study from 2001 to 2002 and from 2011 to 2012. Materials included autopsy reports, toxicological screening during autopsy and data from the Danish national health registers, including psychiatric diagnoses from psychiatric hospitals and ambulatory functions, dispensed prescription use from pharmacies and registered treatment for drug use disorders. Results: In 2001-2002, 63.3% of the decedents had only positive toxicology, 22.5% also had psychiatric morbidity, and 14.2% had a dual diagnosis. In 2011-2012, 56.4% had only positive toxicology, 26.1% also had psychiatric morbidity, and 17.5% had a dual diagnosis. None of the changes were significant. Decedents with only positive toxicology became older at time of death over time; decedents with psychiatric morbidity and a dual diagnosis did not. The prevalence of nonprescribed psychotropic medication, methadone and benzodiazepines increased. Conclusion: Decedents with psychiatric morbidity and dual diagnosis did not increase their lifespan over a 10-year period. Decedents with only positive toxicology increasingly consumed nonprescribed psychotropic medication and may have suffered from undiagnosed psychiatric disorders. The prevalence of prescribed and nonprescribed benzodiazepines and methadone increased and may have contributed to premature mortality.
... Buprenorphine is highly effective at reducing opioid-related mortality and can be provided in office settings. 1,2 As of 2017, however, nearly half of US counties lacked even one prescriber. 3,4 Stigma is a major reason for the suboptimal uptake of buprenorphine, which can be associated with drug use itself and with medication treatment. ...
Article
Background Stigma is a barrier to the uptake of buprenorphine to treat opioid use disorder. Harm reduction treatment models intend to minimize this stigma by organizing care around non-judgmental interactions with people who use drugs. There are few examples of implementing buprenorphine treatment using a harm reduction approach in a primary care setting in the USA.Methods We conducted a qualitative study by interviewing leadership, staff, and external stakeholders at Respectful, Equitable Access to Compassionate Healthcare (REACH) Medical in Ithaca, NY. REACH is a freestanding medical practice that provides buprenorphine treatment for opioid use disorder since 2018. We conducted semi-structured interviews with 17 participants with the objective of describing REACH’s model of care. We selected participants based on their position at REACH or in the community. Interviews were recorded, transcribed, and analyzed for themes using content analysis, guided by the CDC Evaluation Framework.ResultsREACH provided buprenorphine, primary care, and mental health services in a low-threshold model. We identified three themes related to delivery of buprenorphine treatment. First, an organizational mission to provide equitable and low-stigma healthcare, which was a key to organizational identity. Second, a low-threshold buprenorphine treatment approach that was critical, but caused concern about over-prescribing and presented logistical challenges. Third, creation and retention of a harm reduction-oriented workforce by offering value-based work and by removing administrative barriers providers may face elsewhere to providing buprenorphine treatment.ConclusionsA harm reduction primary care model can help reduce stigma for people who use drugs and engage in buprenorphine treatment. Further research is needed to evaluate whether this model leads to improved patient outcomes, can overcome community stakeholder concerns, and is sustainable.
... 5 There is broad consensus among the National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), and World Health Organization (WHO) that people with OUD benefit from medication treatment such as methadone and/or buprenorphine therapy. These medications not only decrease opioidrelated deaths and opioid use [6][7][8] ; people who are receiving treatment are less likely to relapse 9,10 and more likely to be employed and continue working. 11 Additionally, individuals who are receiving medications for opioid use disorder (MOUD) engage in less criminal activity 12 and fewer risky behaviors associated with HIV infection and hepatitis C than those not receiving such treatment. ...
Article
Purpose In response to the opioid crisis, public health advocates urge hospitals to perform substance use disorder (SUD) screening, brief intervention, discharge planning with referral to treatment, and naloxone education. Universal screening makes specialized treatment available to all patients and decreases stigma around SUDs, allowing patients and providers to address SUDs during their hospitalization. Additionally, hospital and emergency department–initiated medications to treat SUD improve patient engagement with treatment and decrease opioid use, and use of medications for opioid use disorder after nonfatal overdoses decreases mortality. Summary A substance use intervention team (SUIT) service was established to offer universal screening and consultation by an interdisciplinary team at our urban academic medical center. The SUIT program provides inpatient consultation services as well as medical and behavioral clinic visits to transition patients to long-term treatment and is comprised of physicians, nurse practitioners, a clinical pharmacist, social workers, and a nurse. Successes attributed to enhanced medication use as a function of having a designated pharmacist as an integral member of the team are highlighted. Our medical center initiated screening efforts in tandem with its interdisciplinary team and clinic. The team attempts to start appropriately selected patients with SUD on medications for SUD while hospitalized. From January through December 2018, 87.2% of patients admitted to the hospital received initial SUD screening. Of the patients who screened positive, 1,400 received a brief intervention by a unit social worker; the SUIT service was consulted on 880 patients, and multiple medications for SUD were started during inpatient care. Conclusion A screening, brief intervention, and referral to treatment service was successfully implemented in our hospital, with the SUIT program in place to provide interdisciplinary addiction care and initiate medications for SUD in appropriate patients.
... Needle and syringe programs (NSP) and opioid substitution treatment (OST) are the most efficient tools for preventing the spread of blood-borne diseases among PWID (Drucker et al., 1998;Gowing et al., 2008;Palmateer et al., 2010;Platt et al., 2017;Tilson et al., 2007;Van Den Berg et al., 2007); the latter is also potentially effective in tackling opioid-related overdose deaths (Gibson et al., 2008;Mattick et al., 2009). ...
Article
Background and objectives In Lithuania, injecting heroin and other illicit opioids has dominated high-risk drug use since about 2000. More recently, patients have reported a high-risk use of amphetamines. Newly diagnosed HIV cases among people who inject drugs peaked in 2002 and 2009 and drug-related deaths have been on the increase. Yet research has reported a limited number of available harm-reduction programs. This study aimed to estimate the size of high-risk drug using populations in Lithuania and to apply these estimates in assessing the coverage of opioid substitution treatment (OST) and needle and syringe programs (NSP). Methods We used indirect prevalence estimation methods (HIV and Mortality Multiplier, Capture-Recapture, Truncated Poisson and the Multivariate Indicator Method) to obtain annual prevalence estimates of the population of high-risk opioid users (HROU) and of people who inject drugs (PWID) in Lithuania in 2015/2016. We computed the coverage of OST (the annual percentage of HROU in these programs) and NSP (the number of provided syringes per PWID per year), using the prevalence estimates and the data from drug services. Results There were between 4854 and 12,444 HROU and between 8371 and 10,474 PWID in Lithuania in 2015/2016. In addition, we obtained a preliminary estimate of 4742–7000 high-risk amphetamine users. This constitutes around 2.5–6.5 HROU and 4.4–5.3 PWID per 1000 inhabitants aged 15–64. On average, 9.9–25.5% of HROUs were in OST and an average PWID in Lithuania obtained 19–29 syringes via NSPs during the study period. Conclusions While the current prevalence of high-risk drug use in Lithuania is comparable to other European countries and for PWID, it is above the average; and the coverage of OST and NSP services in this population is markedly lower than in most countries of the European Union and warrants further investment.
... Benefits of MAT are well supported in the literature, with MAT having been shown to reduce illicit opioid use, improve treatment retention, reduce overall healthcare costs, and reduce mortality. [6][7][8][9][10][11][12][13][14] Psychosocial interventions are recommended to be used in combination with MAT. Interventions vary depending on treatment setting, provider training and/ or competence, and individual patient needs. ...
Article
Purpose: The impact of a focused inpatient educational intervention on rates of medication-assisted therapy (MAT) for veterans with opioid use disorder (OUD) was evaluated. Methods: A retrospective cohort analysis compared rates of MAT, along with rates of OUD-related emergency department (ED) visits and/or hospital admission within 1 year, between veterans with a diagnosis of OUD who completed inpatient rehabilitation prior to implementation of a series of group sessions designed to engage intrinsic motivation to change behavior surrounding opioid abuse and provide education about MAT (the control group) and those who completed rehabilitation after implementation of the education program (the intervention group). A post hoc, multivariate analysis was performed to evaluate possible predictors of MAT use and ED and/or hospital readmission, including completion of the opioid series, gender, age (>45 years), race, and specific prior substance(s) of abuse. Results: One hundred fifty-eight patients were included: 95 in the control group and 63 in the intervention group. Rates of MAT were 25% (24 of 95 veterans) and 75% (47 of 63 veterans) in control and intervention groups, respectively (P < 0.01). Gender, completion of the opioid series, prior heroin use, and marijuana use met prespecified significance criteria for inclusion in multivariate regression modeling of association with MAT utilization, with participation in the opioid series (odds ratio [OR], 9.56; 95% confidence interval [CI], 4.36-20.96) and prior heroin use (OR, 3.26; 95% CI, 1.18-9.01) found to be significant predictors of MAT utilization on multivariate analysis. Opioid series participation and MAT use were independently associated with decreased rates of OUD-related ED visits and/or hospital admission (hazard ratios of 0.16 [95% CI, 0.06-0.44] and 0.32 [95% CI, 0.14-0.77], respectively) within 1 year after rehabilitation completion. Conclusion: Focused OUD-related education in a substance abuse program for veterans with OUD increased rates of MAT and was associated with a decrease in OUD-related ED visits and/or hospital admission within 1 year.
... Naltrexone has limited utility, however, as patients must be opioid-abstinent for 7 to 10 days before beginning treatment (Minozzi et al., 2011). In addition, buprenorphine and methadone, which are opioid agonists, are shown to reduce both all-cause and overdose-related mortality in people with OUD (Gibson et al., 2008;Schuckit, 2016), and they are associated with a reduced number of opioid-related overdose deaths in the community (Pierce et al., 2016;Schwartz et al., 2013). They are also deemed controlled under the Controlled Substances Act due to their abuse potential as opioid agonists, and their distribution is thus regulated by the Drug Enforcement Agency (DEA). ...
Article
In October 2018, President Trump signed into law H.R. 6, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act. This piece of legislation addresses treatment, prevention, recovery, and enforcement with particular attention to access in rural areas. It contains numerous provisions to improve needed access to treat substance use disorders and especially opioid use disorder (OUD), including mandatory coverage of medications for OUD, partial elimination of Medicaid payment for inpatient mental health treatment, and state planning grants to increase provider capacity. Many of these provisions would be significantly enhanced by removing barriers to prescriptive authority for Advanced Practice Registered Nurses (APRNs), including Nurse Practitioners, Clinical Nurse Specialists, Certified Nurse Midwives, Certified Registered Nurse Anesthetists, and other state-specific titles for nurses whose scope allows the prescription of controlled substances. This policy brief includes a history of the role of APRNs in the delivery of medications for OUD, scope of practice restrictions related to prescriptive authority as a barrier in their ability to deliver care for this vulnerable population, and actionable strategies that APRNs can take to advocate for an increased role in providing care.
... Methadone maintenance treatment (MMT) is an effective strategy to decrease illicit opioid use, HIV risk behaviors, deaths due to overdose and criminal activity, while simultaneously improving the social functioning and the quality of life of people with opioid use disorder (OUD). [5][6][7][8] Moreover, several studies indicate that MMT is a cost-effective strategy to reduce the negative consequences of OUD. [9][10][11] Colombia has implemented MMT programs since 2004. ...
Article
Colombia has experienced a dramatic increase of heroin use in the last 3 decades, stablishing the first methadone maintenance treatment (MMT) program in 2004. Although international evidence indicates that MMT has important benefits for people with opioid use disorder, technical and logistical difficulties have been identified in Colombia that can compromise the effectiveness of this treatment modality. In this cross-sectional study, a total of 148 subjects with opioid use disorder were interviewed in the city of Armenia (Colombia) using the Opiate Treatment Index, comparing the drug use, social functioning, human immunodeficiency virus risk behaviors, criminal activity, and the physical/mental health among subjects involved in MMT and those not receiving treatment. Despite the above-mentioned difficulties, subjects participating in MMT reported less illegal substance use (specifically heroin and basuco), less human immunodeficiency virus risk behaviors, better social functioning, less criminal activity, and less physical and mental health problems than those not receiving treatment. In addition, subjects involved in MMT reported a daily use of heroin and lower than recommended dosages of methadone. Therefore, Colombia should continue expanding MMT programs across the country, integrating the available harm reduction strategies and providing continuous training for health professionals in charge of these programs.
... The primary outcomes studied in the literature on OBOT include impacts on mortality, retention in care, and rates of relapse. There is a growing body of research demonstrating significantly decreased all-cause mortality when patients with OUD are treated with buprenorphine [43,[113][114][115][116][117][118]. However, treatment retention is a major challenge that stands in the way of achieving optimal treatment outcomes, and studies suggest rates are lower for patients on buprenorphine compared to methadone [117][118][119][120][121]. ...
Article
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Purpose of review: The rising prevalence of opioid use disorder (OUD) and related complications in North America coupled with limited numbers of specialists in addiction medicine has led to large gaps in treatment. Primary care providers (PCPs) are ideally suited to diagnose and care for people with OUD and are increasingly being called upon to improve access to care. This review will highlight the recent literature pertaining to the care of patients with OUD by PCPs. Recent findings: The prevalence of patients with OUD in primary care practice is increasing, and models of office-based opioid treatment (OBOT) are evolving to meet local needs of both ambulatory practices and patients. OBOT has been shown to increase access to care and demonstrates comparable outcomes when compared to more specialty-driven care. OBOT is an effective means of increasing access to care for patients with OUD. The ideal structure of OBOT depends on local factors. Future research must explore ways to increase the identification and diagnosis of patients with OUD, improve treatment retention rates, reduce stigma, and promote interdisciplinary approaches to care.
... Medication is the gold-standard treatment for opioid use disorder (OUD) and includes opioid agonist treatment (OAT) with buprenorphine (partial agonist) or methadone (full agonist), or naltrexone (antagonist) (National Academies of Sciences and Medicine, 2019). Medication for OUD, such as OAT, has been demonstrated to reduce the risk of fatal overdose (Darke and Hall, 2003;Gibson et al., 2008;Van den Brink and Haasen, 2006;Volkow et al., 2014). Despite this, OAT is underutilized in the treatment of OUD (Volkow et al., 2014), and there is a significant gap between OUD treatment need and OAT capacity nationally (Jones et al., 2015;Mojtabai et al., 2019). ...
Article
Background: Criminal justice referral to treatment is associated with reduced odds of receiving opioid agonist treatment (OAT), the gold-standard treatment for opioid use disorder. States vary substantially in the extent of criminal justice system involvement in opioid treatment; however, the effects on treatment provision are not clear. We examined whether state-level criminal justice involvement in the substance use treatment system modified the association between criminal justice referral to treatment and OAT provision among opioid treatment admissions. Methods: We conducted a random effects logistic regression to investigate how the effects of criminal justice referral to treatment on OAT provision differed in states with high vs. low state-level criminal justice involvement in opioid treatment, adjusting for individual and state-level covariates, among 22 states in the 2015 Treatment Episode Dataset-Admissions. Results: Criminal justice referral to treatment was associated with an 85% reduction in the odds of receiving OAT, compared to other sources of treatment referral (OR = 0.15; 95% CI: 0.15, 0.16). Among opioid treatment admissions resulting from criminal justice referral in 2015, receiving treatment in high criminal justice involvement states was associated with a 63% reduction in the odds of OAT provision, compared to opioid treatment received in low criminal justice involvement states (interaction OR = 0.37, 95% CI: 0.11, 0.89). Conclusion: The effects of criminal justice referral to treatment on OAT provision varied by criminal justice involvement in opioid treatment at the state level. Targeted interventions should increase access to OAT in states that rely on the criminal justice system for opioid treatment referrals.
... 63 For example, one language strategy is to reframe MAT away from "maintenance." 64 While maintenance is associated with reduced risk of overdose 65 and is a treatment goal for many providers and patients, the word maintenance can be stigmatizing for some people who use drugs or people with histories of SUD. Maintenance may be associated with drug use that has caused harm (e.g., "maintaining on heroin") and has in many contexts been used with the stigmatizing word "habit" (e.g., "maintaining a habit"). ...
Article
There is consensus in the scientific literature that the opioid agonist medications methadone and buprenorphine are the most effective treatments for opioid use disorder. Despite increasing opioid overdose deaths in the United States, these medications remain substantially underutilized. For no other medical conditions for which an effective treatment exists is that treatment used so infrequently. In this commentary, we discuss the potential role of stigma in the underutilization of these opioid agonist medications for addiction treatment. We outline stigma toward medications for addiction treatment and suggest that structural and policy barriers to methadone and buprenorphine may contribute to this stigma. We offer pragmatic public health solutions to reduce stigma and expand access to these effective treatments.
... L'efficacité des mesures de RdRD en termes de prévention du VIH et les antirétroviraux ont participé à la fin de l'hécatombe dès 1996 (2) , permettent maintenant à l'espérance de vie des sujets VIH de se rapprocher progressivement de celle de la population générale, lorsqu'ils sont traités de manière précoce, efficace et prolongée avec un taux de CD4 maintenu (33) . Les traitements agonistes opioïdes (TAO : méthadone et buprénorphine en France) ont également eu un impact considérable sur la réduction de la mortalité en général (34) et par overdose en particulier (35) , notamment en France où la mise sur le marché dès 1995 de la méthadone, puis surtout de la buprénorphine haut dosage à large échelle, a permis une réduction spectaculaire de la mortalité par overdose (36) . Cependant, les données du dispositif DRAMES de l' ANSM, montrent, malgré leurs limites, une croissance à nouveau progressive des overdoses avec une place importante des opioïdes : parmi les 310 décès directement imputables à la prise de substances recensés en 2012, 234 (75 %) étaient directement attribuables à des opioïdes dont 187 (80 %) à des TAO, majoritairement la méthadone 140 (60 %). ...
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Les conduites addictives : prévention et prise en soins > Alcool, tabac, jeux, écrans, drogues… Parmi les aides et secours auxquels contribue la Croix-Rouge figure la lutte contre les addictions. De légères à immodérées, ces dépendances ou comportements irrépressibles nuisent aux individus jusqu’à devenir de véritables prisons psychologiques, avec des risques de santé physique et une mise en marge sociale. Cet ouvrage témoigne de cette réalité et illustre les actions de terrain tant du côté des difficultés à surmonter que des résultats obtenus. > Ce recueil d’expériences de professionnels de disciplines variées constitue une référence, voire une source d’accompagnement, autant pour les personnes addictives que pour leurs soignants. Sans éluder la complexité des problèmes, elle fait apparaître - heureusement - quelques perspectives de progrès.
... These could be related to the substance itself or its route of administration, such as liver disease, HIV (Human Immunodeficiency Virus) and bacterial infections (Gibson et al., 2008). The adoption of evidence-based interventions like supervised injecting facilities, needle exchange programmes and outreach programmes for illicit drug users is considered to be an effective overarching policy approach for reducing harm (Ritter & Cameron, 2006). ...
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People who use alcohol and other drugs(hereafter “substances”) and who are over the age of 40 are now more likely to die of a non‐drug related cause than people who use substances under the age of 40. This population will therefore potentially need greater access to palliative and end of life care services. Initially, the purpose of this rapid evidence assessment (REA), conducted August 2016–August 2017, was to explore the peer‐reviewed evidence base in relation to end of life care for people with problematic substance use. The following databases were searched using date parameters of 1 January 2004–1 August 2016: Amed, Psycharticles, Ovid, Ageinfo, Medline, Ebscohost, ASSIA, Social Care Online, Web of Knowledge, Web of Science, SSCI, Samsha, NIAAA. Data were extracted using a predefined protocol incorporating inclusion and exclusion criteria. Given the dearth of evidence emerging on interventions and practice responses to problematic substance use, the inclusion criteria were broadened to include any peer‐reviewed literature focussing on substance use specifically and end of life care. There were 60 papers that met the inclusion criteria. These were quality assessed. Using a textual thematic approach to categorise findings, papers fell into three broad groups (a) pain management, (b) homeless and marginalised groups, and (c) alcohol‐related papers. In general, this small and diverse literature lacked depth and quality. The papers suggest there are challenges for health and social care professionals in meeting the end of life needs of people who use substances. Addressing issues like safe prescribing for pain management becomes more challenging in the presence of substance use and requires flexible service provision from both alcohol/drug services and end of life care providers. Work is needed to develop models of good practice in working with co‐existing substance use and end of life conditions as well as prevalence studies to provide a wider context for policy development.
... 36 MATs, most commonly methadone and buprenorphine, have been shown to be effective in helping patients recover and in reducing long-term morbidity and mortality. 37,38 However, MATs continue to be underutilized and many barriers to access and implementation remain for patients with opioid use disorder. 39,40 There are limited data on the optimal perioperative management of MATs, with differing expert opinion on their management in the perioperative period. ...
Article
Introduction and objectives: Opioid use disorder has become increasingly prevalent in recent years. Previous studies have shown that patients with opioid use disorder undergoing orthopedic, elective abdominopelvic, and cardiac procedures have poorer postoperative outcomes. The aim of this study was to examine the effect of pre-existing opioid use disorder on postoperative outcomes including in-hospital mortality, hospital length of stay (LOS), hospital readmission, and postoperative complications in patients undergoing appendectomy or cholecystectomy. Methods: The authors used administrative data from the State Inpatient Databases of the Healthcare Cost and Utilization Project for the years 2007-2014 from California, Florida, Kentucky, Maryland, and New York. The authors compared unadjusted rates of in-hospital mortality, postoperative complications, LOS, and 30-day and 90-day readmission status. The authors calculated the adjusted odds ratio (OR) for their outcomes using logistic regression models. Results: In all, 488,981 appendectomy patients and 790,491 cholecystectomy patients aged ≥ 18 years were included in the analysis. Appendectomy (OR 2.26) but not cholecystectomy patients with opioid use disorder had statistically significant adjusted odds of in-hospital death. Patients with opioid use disorder (overall reported, and by each procedure separately) had higher adjusted odds of postoperative complication (OR 1.46), 30-day readmission (OR 1.80), 90-day readmission (OR 1.98), and longer LOS (OR 1.37). Conclusions: The authors found higher unadjusted rates and adjusted ORs of in-patient mortality, hospital readmission, and postoperative complications in patients with opioid use disorder undergoing common abdominal surgeries. The authors' study shows that opioid use disorder is a risk factor for poorer postoperative outcomes in this surgical patient population. PMID: 31343725
... Methadone and buprenorphine, which are full and partial agonists respectively, have substantial research supporting their efficacy with OUDs, including decreased opioid-related mortality Gibson et al., 2008;Schwartz et al., 2013), improved treatment retention (Connock et al., 2007;Mattick et al., 2009;Thomas et al., 2014), reduced subsequent drug use (Perry et al., 2013;Thomas et al., 2014), reduced HIV risk behavior (Meltzer et al., 2011), and reduced recidivism Perry et al., 2013). Injectable naltrexone has been shown to decrease rate of relapse (over 24-weeks), increase time to relapse, and reduce subsequent drug use (Lee et al., 2015); however, less is known about the long-term use of injectable naltrexone. ...
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Background: There is a gap between evidence-based treatment with medications for opioid use disorders (OUDs) and current practices of probation departments who supervise individuals with OUDs. Many probationers with OUDs cannot access FDA-approved medications to treat their disorders despite the strong evidence of their effectiveness. The barriers to medications for those under probation supervision include practitioners' negative attitudes toward medications, costs, stigma, and diversion risk. Probation officers have an ethical obligation to help their clients reduce barriers to access the care they need which in turn can improve their outcomes and increase public safety. Results: The current study explores how probation departments respond to probationers with OUDs, focusing on the barriers to accessing OUD medications based on a survey of probation department directors/administrators (hereafter referred to as probation department leaders) in Illinois (N = 26). A majority of probation department leaders reported perceived staff barriers to their clients accessing medications. Reasons included lack of medical personnel experience, cost, need for guidance on medications, and regulations set by their organization or jurisdiction that prohibit client use of medications. Probation department leaders reported knowing less about the use of methadone and how it is administered, compared to buprenorphine and naltrexone. In addition, probation department leaders were generally more open to referring clients for treatment that include buprenorphine or naltrexone compared to methadone. Despite slightly less training or familiarity with methadone than the other medications, the number of probation department leaders who knew where to refer someone for each of the three FDA-approved medications was similar. Conclusions: The current study found probation department leaders perceive some barriers to their staff linking or referring their clients to OUD medications. Study findings indicate a need for administration- and staff-level training, interagency collaboration, and policy changes to increase access to, education on, and use of, medications for probation clients. Such efforts will ultimately help probation clients with OUDs stabilize and adhere to other probation requirements and engage in behavioral therapy, which may result in positive outcomes such as reduced recidivism, increased quality of life, and reduced mortality.
... Research demonstrates OAT reduces overdose and mortality risk [114][115][116]. Naltrexone can reduce the risk of post-release opioid relapse, but its effect on opioidrelated overdose mortality among PRJP is less clear [117][118][119]. ...
Article
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Abstract Post-release opioid-related overdose mortality is the leading cause of death among people released from jails or prisons (PRJP). Informed by the proximate determinants framework, this paper presents the Post-Release Opioid-Related Overdose Risk Model. It explores the underlying, intermediate, proximate and biological determinants which contribute to risk of post-release opioid-related overdose mortality. PRJP share the underlying exposure of incarceration and the increased prevalence of several moderators (chronic pain, HIV infection, trauma, race, and suicidality) of the risk of opioid-related overdose. Intermediate determinants following release from the criminal justice system include disruption of social networks, interruptions in medical care, poverty, and stigma which exacerbate underlying, and highly prevalent, substance use and mental health disorders. Subsequent proximate determinants include interruptions in substance use treatment, including access to medications for opioid use disorder, polypharmacy, polydrug use, insufficient naloxone access, and a return to solitary opioid use. This leads to the final biological determinant of reduced respiratory tolerance and finally opioid-related overdose mortality. Mitigating the risk of opioid-related overdose mortality among PRJP will require improved coordination across criminal justice, health, and community organizations to reduce barriers to social services, ensure access to health insurance, and reduce interruptions in care continuity and reduce stigma. Healthcare services and harm reduction strategies, such as safe injection sites, should be tailored to the needs of PRJP. Expanding access to opioid agonist therapy and naloxone around the post-release period could reduce overdose deaths. Programs are also needed to divert individuals with substance use disorder away from the criminal justice system and into treatment and social services, preventing incarceration exposure.
... Обзоры и лекции рапии и различными другими положительными жизненными изменениями, напрямую не связанными с употреблением опиоидов [3,5]. Существенным явлением, которое может указывать на необходимость максимального удержания в программах ЗТМ, является не только снижение смертности у пациентов ЗТМ по сравнению с потребителями уличных наркотиков, но и рост смертности в случаях исключения или раннего отказа от ЗТМ [6,7]. ...
Article
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92 patients with methadone substitution therapy who were divided in different groups: withdrawn during the year (8.7 %), those who remained on treatment (91.3 %); and withdrawn in 2 years (19.6 %), continued treatment for 2 years (80.4 %). There were no significant differences between the groups in sex, age, age at starting MMT, HIV status, hepatitis C status, marital status, number of children, hereditary complications, smoking, drug use and other characteristics included in EuropASI. In the general group, a high incidence of psychotropic drugs for self-treatment (74.7 %), a high level of depressive (89 %) and anxious (80.2 %) symptoms, high incidence of aggressive behavior (78 %) and suicidal manifestations: suicidal thoughts (59.3 %) and suicidal attempts (36.3 %), 68.9 % reported about child abuse. There were significant differences between groups in the recent experience of using psychotropic drugs without prescribing a doctor (χ 2 = 13,271, df = 3, p = 0,004), the presence of suicidal thoughts (χ 2 = 14,350, df = 3, p = 0,002), anxious symptoms (χ 2 = 8.96, df = 3, p = 0,03), positive attitude to labor (χ 2 = 6,01; df = 2, p = 0,05), experience of detainees (χ 2 = 4,298, df = 1, p = 0,038), companies without the use of psychoactive substances (χ 2 = 5,606, df = 1, p = 0,018), psychoses associated with the use of psychoactive substances (χ 2 = 10,89, df = 2, p = 0,004).
... Overall mortality is reduced by 50% during treatment with pharmacotherapy [66] as is overdose death [67], an effect that appears to be moderated by exposure: the longer the treatment, the greater the reduction in mortality [68]. Retention in treatment varies in the literature, although methadone is associated with greater treatment retention than buprenorphine [69•] and buprenorphine discontinuation is primarily involuntary, that is, due to failure to follow strict program requirements [70]. ...
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Purpose of Review Opioid overdoses have risen starkly over the last two decades in the USA and are now among the leading causes of overall mortality. This review summarizes the current literature on risk factors for overdose as well as public health solutions. Recent Findings Although opioid overdose mortality is highest among men and non-Hispanic whites, the rate of death is rising more rapidly now among women and non-Hispanic blacks. Incarceration remains a significant risk factor for overdose death, especially in the first weeks upon reentry reflecting the absence of treatment in prisons and jails despite strong evidence for the benefits of pharmacotherapy integration into these settings. Pharmacotherapy with either methadone or buprenorphine greatly reduces the risk of overdose; however, treatment discontinuation leads to an increase risk of death. Summary Naloxone distribution both through co-prescribing and community-based opioid overdose prevention programs remains the fundament of the public health response. Both are effective and cost-effective in reducing overdose; however, uptake is hampered due to variance in state naloxone access and Good Samaritan laws. Supervised injection facilities are a promising innovation to address overdose, especially in communities with high overdose rates.
Article
Opioid use disorder occurs worldwide and creates an increasing economic burden and public health crisis. Some problems are associated with using opioid agonists; therefore, there is a need to develop non-opioid treatments to improve acute and long-term opioid withdrawal syndromes. We will enroll 100 participants with opioid use disorders receiving methadone maintenance treatment at an addiction treatment center and randomly allocate them to an experimental or control group. The experimental group will receive 12 sessions of light needle therapy within 4 weeks, while the control group will receive sham light needle treatment without any laser output. Urinary morphine levels were assessed before and after treatment. Participants will be asked to self-report their number of episodes or days of heroin use and heroin craving/refusal to use heroin in the previous week before and after treatment on a visual analogue scale score of 0 to 10. Quality of life will be reported using the Short Form-12v2 before and after 4 weeks of treatment. Pulse diagnosis and heart rate variability will be evaluated before and after treatment. Baseline patient characteristics will be compared between the groups using the independent t test and the χ2 test. Data between the 2 groups will be compared using generalized estimation equations, and paired t tests. This study aims to investigate the effect of adjuvant light needle therapy in patients with opioid use disorder on methadone maintenance treatment.
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Background: Opioid substitution therapy (OST) is endorsed as the recommended treatment for opioid use disorders. Opioid substitution therapy is not widely used in South Africa, so little is known about its perceived clinical utility in this setting. There is also a paucity of qualitative research that explores the subjective experiences of patients using OST. Aim: To explore patients’ perceptions and experiences attending a South African OST outpatient clinic (OST-OC). Setting: The OST-OC at Stikland Psychiatric Hospital, Cape Town, South Africa. Methods: We conducted a qualitative study using semi-structured interviews with eight participants who had been attending the OST-OC for at least 6 months. Transcripts were analysed using Atlas.ti software and thematic content analysis was used to identify themes. Results: Patients stated that OST helped them to regain and maintain a stable lifestyle. Autonomy and agency, the therapeutic relationship and family support were perceived as contributing to successful patient outcomes. The preference for methadone and buprenorphine treatment depended on individual experiences. Patients valued kindness from staff members but reported that improved interactions with some nonclinical staff could better facilitate treatment. Challenges experienced included stigma and cost. Conclusions: This study offers insights about OST that are pertinent to low- and middle-income countries. Reducing the cost of OST, collaborative decision-making between staff and patients, and a non-judgemental attitude by clinical staff were recognised as important factors for optimised service delivery. Contribution: Understanding patients’ experiences of OST in a South African setting will allow for future policy development for the treatment of opioid use disorders in similar settings locally and abroad.
Article
Objective: This study evaluated the presence of drug-free family and friends in the social networks of patients treated in an inpatient setting for co-occurring psychiatric disorders and substance use problems. Methods: Social network interviews were conducted with inpatients at the Johns Hopkins Bayview Acute Psychiatric Unit with co-occurring psychiatric disorders and substance use problems (N = 90). Results: Participants reported about five social network members, of which four were drug-free. Most participants (> 70%) were willing to include a drug-free person in the current inpatient treatment plan to support recovery efforts (M = 1.8 network members) and identified several areas of recovery support. Conclusions: These results demonstrate that people treated in an inpatient psychiatric setting have local drug-free family or friends that they are willing to include in the treatment process. These findings support further study of methods to mobilize network members to enhance social support during and following hospitalization.
Article
The National HIV/AIDS Strategy for 2022-2025 and the federal Ending the HIV Epidemic (EHE) initiative1,2 have an ambitious goal of dramatically reducing new HIV infections in the United States. by 90% by 2030. While we have the tools to achieve that, the persistent barriers to healthcare services experienced by too many individuals will need to be addressed to make significant progress and improve the health and quality of life of all people living with HIV. The necessary structural changes require actions by federal, state and local policymakers and range from ensuring universal access to healthcare services to optimizing care delivery to ensuring a robust and diverse ID and HIV workforce. This paper outlines ten key principles for policy reforms that if advanced would make ending the HIV epidemic in the U.S. possible and could have much more far-reaching effects in improving the health of our nation.
Article
Background People with opioid use disorder (OUD) experience lower quality of life (QoL) than the general population, but buprenorphine treatment for OUD could help improve QoL of individuals with OUD. Thus, we conducted a systematic review and meta-analysis of the impact of buprenorphine on QoL among people with OUD. Methods Seven databases were searched through August 2020. We included English-language studies with pre- and post- QoL assessments internationally. Standardized mean differences were calculated for five domains of QoL measures using a random effects model for correlated effect sizes with robust variance estimation. Meta-regression was used to assess variation in effect sizes based on QoL domain, treatment, and patient factors. Results Twenty-one peer-reviewed studies from twelve countries were included. Only three studies included a no-treatment control group and five studies assigned groups using randomization. Improvements between baseline and follow-up were observed across all five domains of QoL measures (overall, physical, psychological, social, and environmental). The certainty of evidence was low for all domains of QoL, and very low for environmental QoL. We did not observe differences in the effect of buprenorphine on QoL by QoL domain, duration, dose, participant characteristics, or adjunctive counseling services. Conclusions Buprenorphine treatment likely improves overall, physical, psychological, and social QoL, and may improve environmental QoL, for individuals with OUD. Findings are limited by study quality, including lack of control groups and incomplete reporting. Future studies with more rigorous methods and comprehensive reporting are needed.
Article
Appropriate clinical management of opioid withdrawal is a crucial bridge to long‐term treatment for opioid use disorder (OUD), as it is a high‐risk time for potential opioid overdose and relapse. We provide a narrative review of evidence‐based opioid withdrawal management strategies applicable to a variety of treatment settings and geographies. The goals of opioid withdrawal management include relieving suffering associated with withdrawal, providing appropriate diagnosis and screening, engaging patients in initiation of OUD treatment, and employing harm reduction strategies, all guided by a patient‐centered approach to care. In addition, we discuss complex cases, relapse prevention strategies, and new developments in opioid withdrawal management.
Article
Introduction The mainstay of pharmacological management of opioid dependence is opioid substitution treatment. Methadone is a long‐acting opioid agonist, which is used for detoxification and maintenance of opioid-dependent people. Objective Objective of the present evaluation included a comparison between methadone and acetaminophen codeine plus clonidine for management of opioid withdrawal symptoms. Methods All patients of an acute ward of a psychiatric hospital, who met dual diagnosis of primary psychiatric disorder plus opioid use disorder, were selected as accessible sample for the current evaluation. Duration of assessment was around elven months and the study was performed according to a single-blind plan. Among 96 patients, cases, who were using methadone, before their recent admission in hospital, continued their substitution treatment according to the recommended dosage and formulation till release (n = 42). The remaining group of patients, had been given acetaminophen codeine plus clonidine, as substitution treatment, during their inpatient management (n = 54). The primary outcome measures were the ‘Cross-Cutting Symptom Measure’ and the ‘Subjective Opiate Withdrawal Scale’, which were scored at baseline, week 1 and week 2. The study was performed according to the ‘per-protocol’ analysis, and the assessor was blind with respect to the said protocols. Results while the mean total score of primary outcome measures decreased significantly in both groups, the between-group analysis did not show any significant difference between these two groups in a head-to-head analysis. Conclusion Acetaminophen codeine plus clonidine was as good as methadone for management of opioid withdrawal symptoms in inpatient setting.
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Methadone, a widely‐prescribed medication for chronic pain and opioid addiction, is associated with respiratory depression and increased predisposition for torsades de pointes, a potentially fatal arrhythmia. Most methadone‐related deaths occur during sleep. The objective of this study was to determine whether methadone’s arrhythmogenic effects increase during sleep, with a focus on cardiac repolarization instability using QT variability index (QTVI), a measure shown to predict arrhythmias and mortality. Sleep study data of 24 patients on chronic methadone therapy referred to a tertiary clinic for overnight polysomnography were compared with two matched groups not on methadone: 24 patients referred for overnight polysomnography to the same clinic (Clinic group), and 24 volunteers who had overnight polysomnography at home (Community group). Despite similar values for heart rate, heart rate variability, corrected QT interval, QTVI and oxygen saturation (SpO2) when awake, patients on methadone had larger QTVI (p=0.015 vs Clinic, p<0.001 vs Community) and lower SpO2 (p=0.008 vs Clinic, p=0.013 vs Community) during sleep, and the increase in their QTVI during sleep versus wakefulness correlated with the decrease in SpO2 (r=‐0.54, p=0.013). QTVI positively correlated with methadone dose during sleep (r=0.51, p=0.012) and wakefulness (r=0.73, p<0.001). High‐density ectopy (>1000 premature beats per median sleep period), a precursor for torsades de pointes, was uncommon but more frequent in patients on methadone (p=0.039). This study demonstrates that chronic methadone use is associated with increased cardiac repolarization instability. Methadone’s pro‐arrhythmic impact may be mediated by sleep‐related hypoxemia which could explain the increased nocturnal mortality associated with this opioid.
Article
Background: The efficacy of methadone in reducing morbidity and mortality associated with opioid use disorder is supported by a wealth of evidence, yet methadone retention is often poor. While crystal methamphetamine (methamphetamine) use has been recently increasing in many countries, the effect of frequency of methamphetamine use on methadone discontinuation has not been investigated. We aimed to examine whether frequency of methamphetamine use is associated with increased rates of methadone discontinuation among individuals on methadone. Design: Two harmonized ongoing open prospective cohort studies of community-recruited people who use illicit drugs with semi-annual follow-ups between 2014 and 2018. Setting: Vancouver, Canada. Participants: A community recruited sample of people who use drugs. Intervention: A time-varying variable of self-reported methamphetamine use frequency within the past six months. Measurements: The primary outcome was time to discontinuation of methadone, defined as reporting not being on methadone at the time of a follow-up interview during the study period. We employed multivariable extended Cox regression analysis to examine the relationship between frequency of methamphetamine use and time to methadone discontinuation after adjusting for potential confounders. Findings: Of 875 eligible participants who contributed 2319 person-years of follow-up, 284 (32.5 %) discontinued methadone at least once during follow-up and 135 (15.4 %) reported more than weekly methamphetamine use at study baseline. In a multivariate analysis, in comparison to no use, ≥weekly use of methamphetamine remained independently associated with methadone discontinuation (adjusted hazard ratio [aHR] = 1.38, 95 % CI = 1.03-1.85). Conclusions: A significant proportion of participants on methadone in this study reported more than weekly crystal methamphetamine use, which was associated with an increased risk of methadone discontinuation. Closer follow up, education, and treatment of methamphetamine use may be needed for this group to improve methadone retention.
Article
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Background The incidence of opioid use disorder (OUD) is increasing worldwide, and the opioid-related overdose crisis is currently a major global challenge. This study investigated the effects of adjuvant laser meridian massage (LMM) in men with OUD undergoing methadone maintenance treatment (MMT). Methods A case-controlled study was conducted from February 2019 to April 2020. Fourteen men with OUD on MMT were enrolled from an addiction treatment center as an experimental group. An age-matched control group comprising 13 men was also enrolled. The experimental group received LMM on the back, including over the Bladder meridian and Governor Vessel, three times weekly for 4 weeks. The control group received only MMT. Urinary morphine levels, patients’ self-reports of the number of episodes or days of heroin use, and visual analog scale scores for heroin craving/refusal to use heroin during the previous week were evaluated. Quality of life was reported using the Short Form (SF)-12v2. Results The experimental group showed a significant decrease in heroin use (P<0.05), whereas the control group showed a significant increase in heroin craving (P<0.05). The SF-12v2 Health Survey revealed a significant improvement in physical health in the experimental group (P<0.05). Conclusions The results of this study suggest that laser meridian massage can be considered a safe, well-tolerated, and potentially useful adjuvant intervention for opioid use disorder.
Article
The opioid epidemic is one of the greatest public health problems that the USA faces. Opioid overdose death rates have increased steadily for more than a decade and doubled in 2013–17, as the highly potent synthetic opioid fentanyl entered the drug supply. Demographics of new HIV diagnoses among people who inject drugs are also changing, with more new HIV diagnoses occurring among White people, young people (aged 13–34 years), and people who reside outside large central metropolitan areas. Racial differences also exist in syringe sharing, which decreased among Black people and Hispanic people but remained unchanged among White people in 2005–15. Recent HIV outbreaks have occurred in rural areas of the USA, as well as among marginalised people in urban areas with robust HIV prevention and treatment services (eg, Seattle, WA). Multiple evidence-based interventions can effectively treat opioid use disorder and prevent HIV acquisition. However, considerable barriers exist precluding delivery of these solutions to many people who inject drugs. If the USA is serious about HIV prevention among this group, stigma must be eliminated, discriminatory policies must change, and comprehensive health care must be accessible to all. Finally, root causes of the opioid epidemic such as hopelessness need to be identified and addressed.
Article
Objective Emergency medicine clinicians are uniquely positioned to deliver interventions to enhance linkage to evidence‐based treatment for opioid use disorder (OUD) in the acute overdose period, yet little is known about patient perspectives to effectively engage patients immediately following opioid overdose. Our objective was to explore patients’ perspectives on substance use treatment, perceived needs, and contextual factors that shape the choice of patients seen in the Emergency Department (ED) to engage with treatment and other patient support services in the acute post‐opioid overdose period. Methods We administered a brief quantitative survey and conducted semi‐structured interviews with 24 adult ED patients receiving care after an acute opioid overdose between June 2016 and August 2017 in an urban, academic ED. We used constant comparison method and thematic analysis to identify themes across 4 levels of a modified social ecological model (individual, interpersonal, organizational and structural). Results The average age of the sample was 33.5 years old (SD+/‐ 9.33); 83% white and 12% Black; 67% male; and 83% diagnosed with opioid use disorder, with a mean of 3.25 (SD+/‐2.64) self‐reported lifetime opioid overdoses. Eight themes were identified as influencing participants’ consideration of OUD treatment and other services: (1) perceptions about control of drug use; (2) personal experience with substance use treatment; (3) role of interpersonal relationships; (4) provider communication skills; (5) stigma; (6) availability of ED resources; (7) impact of treatment policies; and (8) supports for unmet basic needs. Conclusions Patients receiving ED care following overdose in our ED are willing to discuss their opioid use and its treatment in the ED and report a variety of unmet needs. This work supports a role for ED‐based research evaluating a patient‐oriented approach to engage patients after opioid overdose.
Chapter
The infectious disease (ID) physician can play an important role in the evidence-based treatment of both opioid use disorder (OUD) and addiction-related infections. A comprehensive ID consultation will include substance-related screening, diagnosis, and initiation of medications for OUD—extended-release naltrexone, buprenorphine, and methadone. This care can be integrated into the treatment of common and uncommon OUD-related infections. Providers should understand patient-centered concepts for persons who use drugs such as acute pain, opioid-related conditions, and reduction of unplanned disposition. Team-based integration of ID and OUD management can improve care and reduce treatment interruptions.
Article
Background Methadone maintenance treatment (MMT) remains the most widely used effective therapeutic approach for opioid use disorders. However, there is paucity of empirical data regarding the relationship between the MMT and survival of subjects with schizophrenia. Aim The aim of this study was to examine the effect of MMT on the long-term survival of subjects with schizophrenia and a lifetime comorbid substance use disorders. Methods The charts of 277 consecutive subjects admitted in our center during a period from January 1, 2002 to February 1, 2007 were assessed. Psychiatric diagnoses have been established according to international classification of diseases and health related problems-10th edition (ICD-10). The risk of all-cause mortality was assessed by Cox proportional-hazards regression models, including time-dependent covariates. Results Out of MMT subjects, 31 (11.2%) had mental and behavioral disorders due to multiple psychoactive substance use, 5 (1.8%) had mental and behavioral disorders due to use of opioids. All of 13 (4.7%) subjects with opioid use disorders were treated. MMT has been found to be predictive of lower long-term survival, in time-independent (hazard ration [HR] = 1.88; 95%CI: 1.06-3.37; p<.05) and in time-dependent adjusted models (HR = 2.01; 95%CI: 1.21-3.60; p<.05). MMT daily dose of <120 mg (adjusted HR = 1.83; 95%CI: .95-3.54) and MMT daily dose of ≥120 mg (adjusted HR = 2.70; 95%CI: .97-7.54) were associated with less long-term survival, all compared with no lifetime MMT (p<.046). Conclusions Among subjects with schizophrenia and a lifetime comorbid substance use disorders, overall mortality was higher in those who received lifetime MMT, then in patients without MMT.
Article
Introduction The opioid use crisis has left nearly 1 million people in need of treatment. States have focused primarily on policies aimed at decreasing the prevalence of opioid use disorder. However, opioid treatment programs (OTPs), an evidence-based modality which can prevent and decrease opioid-related mortality and morbidity, remain highly complex with variation in treatment by state. Evidence-based state-level regulation of OTPs can be a powerful tool and may help improve the unmet need for treatment. This study characterized the variability in state laws that regulate OTPs and examines how this variability is associated with state characteristics. Our data provides an opportunity for policymakers to consider regulations that increase access to care and retention in OTPs, which could improve population health. Materials and methods Utilizing policy mapping techniques, we identified all regulations governing OTPs in effect on January 1, 2017 and determined whether the most common regulations were consistent with best practices. We then examined how the number and type of regulations were associated with state characteristics. All policy mapping research was conducted between November 2017 and March 2019. Results We identified 89 different regulations, the most common of which exists in fewer than half of all states; and most exist in <25% of states. Eighteen of the 30 most common regulations were inconsistent with best practice recommendations. Overall, variability in the number and type of OTP regulations was related to geographic location as opposed to state size. Conclusions Wide-ranging variability exists in the regulations of OTPs across the U.S. Most state OTP regulations are not congruent with best practices.
Article
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The use of pharmacological treatments for opioid use disorders, including methadone, buprenorphine and naltrexone has been associated with a reduction in mortality compared with illicit opioid use. However, these treatments can also contribute significantly to the risk of death. The opioid agonists methadone and buprenorphine achieve clinical efficacy in patients with an opioid use disorder through suppressing craving and diminishing the effectiveness of illicit opioid doses, while the antagonist naltrexone blocks the action of opioids. Pharmacological differences between opioid pharmacotherapies then create different temporal patterns of protection and mortality risk, different risks of relapse to illicit opioid use, and variations in direct and indirect toxicity, which are revealed in clinical and epidemiological studies. Induction onto methadone and the cessation of oral naltrexone treatment are associated with an elevated risk of opioid poisoning, which is not apparent in patients treated with buprenorphine or sustained-release naltrexone. Beyond drug-related mortality, these pharmacotherapies can impact a participant’s risk of death. Buprenorphine may also have some advantages over methadone in patients with depressive disorders or cardiovascular abnormalities. Naltrexone, which is also commonly prescribed to manage problem alcohol use, may reduce deaths in chronic co-alcohol users. Understanding these pharmacologically driven patterns then guides the judicious choice of drug and dosing schedule and the proactive risk management that is crucial to minimising the risk of death in treatment.
Article
Aim: Treatment for opioid use disorders has recently evolved to include long-acting injectable and implantable formulations of medications for opioid use disorder (MOUD). Incorporating patient preferences into treatment for substance use disorders is associated with increased motivation and treatment satisfaction. This study sought to assess treatment preferences for long-acting injectable and implantable MOUD as compared to short-acting formulations among individuals with OUD. Methods: We conducted qualitative, semi-structured telephone interviews with forty adults recruited from across the United States through Craigslist advertisements and flyers posted in treatment programs. Eligible participants scored a two or greater on the heroin or opioid pain reliever sections of the Tobacco, Alcohol, Prescription Medications, and Other Substances (TAPS) Tool, indicative of a past-year OUD. Interviews were transcribed, coded, and thematically analyzed. Results: Twenty-four participants (60%) currently or previously had been prescribed MOUD. Sixteen participants (40%) expressed general opposition to MOUD, citing concerns that MOUD is purely financial gain for pharmaceutical companies and/or a "band aid" solution replacing one drug with another, rather than a path to abstinence. Some participants expressed personal preference for long-acting injectable (n = 16/40: 40%) and implantable formulations (n = 12/40: 30%) over short-acting formulations. About half of the participants were not willing to use injectables (n = 19/40: 48%) or implantables (n = 22/40: 55%), preferring short-acting formulations. Mixed evaluations of long- and short-acting MOUD focused on considerations of medication-related beliefs (privacy, concern over an embedded foreign body), the medication-related burden (convenience, provision of structure and support, medication administration, potential side effects), and medication-taking practices (potential for non-prescribed use, control over dosage, and duration of treatment). Conclusions: Though many participants personally prefer short-acting to long-acting MOUD, some were open to including long-acting formulations in the range of options for those with OUD. Participants felt long-acting formulations may reduce medication-related burden and the risk of diversion. Conversely, participants expressed concern about invasive administration and loss of control over their treatment. Results suggest support for expanded access to a variety of formulations of MOUD. The use of shared decision making may also help patients select the formulation best aligned with their experiences, values, and treatment goals.
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Objective: To determine access to opioid agonist therapy (OAT) for those entering residential treatment for opioid use disorder; to report on treatment outcomes for those taking OAT and those not taking OAT; and to determine the association between OAT use and residential treatment completion. Design: Retrospective cohort study. Setting: Ontario. Participants: Patients with opioid use disorder admitted to publicly funded residential treatment programs in the province of Ontario between January 1, 2013, and December 31, 2016. Main outcome measures: Access to OAT during residential treatment using descriptive statistics. Treatment outcomes (ie, completed the program, voluntarily left early, involuntary discharged, and other) for the entire cohort and for the OAT and non-OAT groups using descriptive statistics. Association between OAT use at admission and treatment completion (a binary outcome) using bivariate and multivariate models. Results: Among an identified cohort of 1910 patients with opioid use disorder, 52.8% entered programs that permitted access to OAT. Overall, 56.8% of patients completed treatment, 23.3% voluntarily left early (eg, were no-shows, dropped out), 17.0% were involuntarily discharged, and 2.9% were discharged early for other reasons. Those taking OAT were as likely to complete treatment as those not taking OAT (53.9% vs 57.5%, respectively; adjusted odds ratio of 1.07, 95% CI 0.77 to 1.38). Conclusion: This study demonstrates 2 large gaps in care for patients with opioid use disorder. First, these patients have poor access to OAT-the first-line treatment of opioid use disorder-while in publicly funded residential treatment programs; and second, many are involuntarily discharged from treatment. Additionally, this study indicates that patients taking OAT have similar likelihood of completing residential treatment as those not taking OAT do. Limitations of this study are that it is based on observational data for patients who self-selected before admission to use OAT or not, and it is likely not all confounders were accounted for.
Technical Report
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This systematic review aims to compare the effects of buprenorphine with methadone on outcomes in women who have been in OMT throughout or in parts of their pregnancies, and on outcomes in fetuses and children who have been prenatally exposed to one of these OMT medications.
Article
The purpose of the study was to describe patient outcomes with a 3-day tramadol taper for acute opioid withdrawal on the detoxification unit at Summa Health System. The primary endpoint was the change in Clinical Institute Narcotic Assessment (CINA) score from the start of the taper until completion or discharge. Secondary endpoints were length of stay, use of adjuvant medications, taper completion rates, highest CINA score, adverse events, and 30-day readmission rates. A retrospective, quality improvement, cohort study was performed describing outcomes of opioid dependent patients in acute withdrawal admitted on the detoxification unit between September 2014 and September 2016 receiving the 3-day tramadol taper. All patients ≥18 years of age admitted for opioid dependence were included. Pregnant patients were excluded. Forty-five patients were included in the analysis. Patient ages ranged from 18-67 and 25 (55.6%) were male. The full taper was completed in 67.7% of admissions and 75.8% of patients were discharged by the physician. There was a statistically significant change of the pre-taper score compared to the score at completion or discharge in the per protocol group (-1.58, p = 0.010). There were no reported seizures or falls. The 3-day tramadol taper proved to be safe and effective therapy for treating acute opioid withdrawal. In the Summa Health System detoxification unit, patients treated with a 3-day tramadol taper for acute opioid withdrawal had their pre-taper CINA scores reduced by over 25% at the completion of the taper or discharge.
Article
Opioid use disorder is characterised by the persistent use of opioids despite the adverse consequences of its use. The disorder is associated with a range of mental and general medical comorbid disorders, and with increased mortality. Although genetics are important in opioid use disorder, younger age, male sex, and lower educational attainment level and income, increase the risk of opioid use disorder, as do certain psychiatric disorders (eg, other substance use disorders and mood disorders). The medications for opioid use disorder, which include methadone, buprenorphine, and extended-release naltrexone, significantly improve opioid use disorder outcomes. However, the effectiveness of medications for opioid use disorder is limited by problems at all levels of the care cascade, including diagnosis, entry into treatment, and retention in treatment. There is an urgent need for expanding the use of medications for opioid use disorder, including training of health-care professionals in the treatment and prevention of opioid use disorder, and for development of alternative medications and new models of care to expand capabilities for personalised interventions.
Article
Pharmacotherapy, or medication-assisted treatment (MAT), is a critical component of a comprehensive treatment plan for the pregnant woman with opioid use disorder (OUD). Methadone and buprenorphine are two types of opioid-agonist therapy which prevent withdrawal symptoms and control opioid cravings. Methadone is a long-acting mu-opioid receptor agonist that has been shown to increase retention in treatment programs and attendance at prenatal care while decreasing pregnancy complications. However methadone can only be administered by treatment facilities when used for OUD. In contrast, buprenorphine is a mixed opioid agonist-antagonist medication that can be prescribed outpatient. The decision to use methadone vs buprenorphine for MAT should be individualized based upon local resources and a patient-specific factors. There are limited data on the use of the opioid antagonist naltrexone in pregnancy. National organizations continue to recommend MAT over opioid detoxification during pregnancy due to higher rates of relapse with detoxification.
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Signed into law in 2016, the landmark 21 st Century Cures Act is as complex as it is divisive. For some stakeholders, including patient groups and representatives of regulated industries, the Act represented a major leap forward in pharmaceutical innovation, human subjects protections, and numerous other provisions. For other observers, this legislation was characterized as a major rollback in important regulations, which would leave patients worse off and the payers holding the bag. The one element of the Act that was relatively uncontroversial covered a number of provisions related to addressing the opioid crisis. This was by design. Provisions related to this issue were not part of the original legislation and were added to win over additional members of Congress who needed to be brought along to support the legislation. Many of the statute's provisions were intertwined with the Comprehensive Addiction Recovery Act (“CARA”) passed previously, but that legislation was stripped of much of its funding for opioid crisis response.
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This article presents a new instrument with which to assess the effects of opiate treatment. The Opiate Treatment Index (OTI) is multi-dimensional in structure, with scales measuring six independently measured outcome domains: drug use; HIV risk-taking behaviour; social functioning; criminality; health; and psychological adjustment. Psychometric properties of the Index are excellent, suggesting that the OTI is a relatively quick, efficient means of obtaining reliable and valid data on opiate users undergoing treatment over a range of relevant outcome domains.
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The purpose of this study was to characterize the acute effects of buprenorphine, an opioid partial mu-agonist, across a wide range of doses in comparison to methadone. Healthy adult male volunteers, who had experience with but were not physically dependent on opioids, participated while residing on a closed research unit. Four subjects received buprenorphine (0, 1, 2, 4, 8, 16, and 32 mg sublingually and five subjects received methadone (0, 15, 30, 45, and 60 mg orally) in ascending order at 1-week intervals. Physiologic, subjective, and behavioral measures were monitored for 96 hours after drug administration. Both drugs produced typical opioid agonist effects (positive mood, sedation, respiratory depression, and miosis), some of which persisted for 24 to 48 hours. A plateau was observed for the dose effects of buprenorphine on subjective measures and respiratory depression. Pharmacokinetic data revealed that plasma concentrations of buprenorphine were linearly related to dose, indicating no limits on sublingual absorption in this dose range. This study shows a plateau on buprenorphine effects, consistent with its partial agonist classification, and that single doses of buprenorphine up to 70 times the recommended analgesic dose are well tolerated by nondependent humans.
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Unlabelled: AIMS/DESIGN: Estimates of mortality associated with illicit opiate use provide useful information to those directing and monitoring local, national and international policies and programmes. Most studies investigating the association have, however, been small with imprecise estimates of increased mortality. The current study combines data from a number of international studies in a meta-analysis to estimate more precisely mortality associated with illicit opiate use. Because HIV infection among injecting drug users differs dramatically between countries and localities, we excluded studies where AIDS was a major contributor to mortality. Studies were included only where AIDS-specific mortality accounted for less than 2% of total mortality. Findings: Our results show a mortality rate for people regularly using illicit opiates, which is more than 13 times greater than that observed for the general community. It is estimated that 9.4% of total mortality in Australians aged 15-39 years of age can be attributed to regular use of illicit opiates. Application of this aetiological fraction to Australian mortality data for 1992 indicate that approximately 401 male and 161 female deaths occurred as a result of opiate use. This represents some 15,429 and 6261 person-years of life lost (to age 70) for males and females, respectively. Conclusions: The mortality rate for illicit opiate users is approximately 13 times greater than for the general population. The large number of years of life lost is reflective of the relatively young population (15-39 years of age) in which opiate-related mortality occurs. Relative risk estimates can also be applied to data on the prevalence of illicit opiate use in other countries to produce locally based aetiological fractions and estimates of person-years of life lost.
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This study evaluated factors associated with accidental fatal drug overdose among a cohort of injection drug users (IDUs). In a prospective cohort study of 2849 IDUs in King County, Washington, deaths were identified by electronically merging subject identifiers with death certificate records. Univariate and multivariate Cox regression analyses were performed to identify predictors of overdose mortality. Thirty-two overdoses were observed. Independent predictors of overdose mortality were bisexual sexual orientation (relative risk [RR] = 4.86; 95% confidence interval [CI] = 2.30, 13.2), homelessness (RR = 2.30; 95% CI = 1.06, 5.01), infrequent injection of speedballs (RR = 5.36; 95% CI = 1.58, 18.1), daily use of powdered cocaine (RR = 4.84; 95% CI = 1.13, 20.8), and daily use of poppers (RR = 22.0; 95% CI = 1.74, 278). Sexual orientation, homelessness, and drug use identify IDUs who may benefit from targeted interventions.
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To compare outcomes, costs and incremental cost-effectiveness of heroin detoxification performed in a specialist clinic and in general practice. Randomised controlled trial set in a specialist outpatient drug treatment centre and six office-based general practices in inner city Sydney, Australia. 115 people seeking treatment for heroin dependence, of whom 97 (84%) were reinterviewed at Day 8, and 78 (68%) at Day 91. Participants were randomly allocated to primary care or a specialist clinic, and received buprenorphine for 5 days for detoxification, then were offered either maintenance therapy with methadone or buprenorphine, relapse prevention with naltrexone, or counselling alone. Completion of detoxification, engagement in post-detoxification treatment, and heroin use assessed at Days 8 and 91. Costs relevant to providing treatment, including staff time, medication use and diagnostic procedures, with abstinence from heroin use on Day 8 as the primary outcome measure. There were no significant differences in the proportions completing detoxification (40/56 [71%] primary care v 46/59 [78%] clinic), participating in postwithdrawal treatment (28/56 [50%] primary care v 36/59 [61%] clinic), reporting no opiate use during the withdrawal period (13/56 [23%] primary care v 13/59 [22%] clinic), and in duration of postwithdrawal treatment by survival analysis. Most participants in both groups entered postwithdrawal buprenorphine maintenance. On an intention-to-treat basis, self-reported heroin use in the month before the Day 91 interview was significantly lower than at baseline (27 days/month at baseline, 14 days/month at Day 91; P < 0.001) and did not differ between groups. Buprenorphine detoxification in primary care was estimated to be $24 more expensive per patient than treatment at the clinic. The incremental cost-effectiveness ratio reveals that, in this context, it costs $20 to achieve a 1% improvement in outcome in primary care. Buprenorphine-assisted detoxification from heroin in specialist clinic and primary care settings had similar efficacy and cost-effectiveness. Buprenorphine treatment can be initiated safely in primary care settings by trained GPs.
Article
Objective: To compare outcomes, costs and incremental cost-effectiveness of heroin detoxification performed in a specialist clinic and in general practice. Design and setting: Randomised controlled trial set in a specialist outpatient drug treatment centre and six office-based general practices in inner city Sydney, Australia. Participants: 115 people seeking treatment for heroin dependence, of whom 97 (84%) were reinterviewed at Day 8, and 78 (68%) at Day 91. Interventions: Participants were randomly allocated to primary care or a specialist clinic, and received buprenorphine for 5 days for detoxification, then were offered either maintenance therapy with methadone or buprenorphine, relapse prevention with naltrexone, or counselling alone. Main outcome measures: Completion of detoxification, engagement in post-detoxification treatment, and heroin use assessed at Days 8 and 91. Costs relevant to providing treatment, including staff time, medication use and diagnostic procedures, with abstinence from heroin use on Day 8 as the primary outcome measure. Results: There were no significant differences in the proportions completing detoxification (40/56 [71%] primary care v 46/59 [78%] clinic), participating in postwithdrawal treatment (28/56 [50%] primary care v 36/59 [61%] clinic), reporting no opiate use during the withdrawal period (13/56 [23%] primary care v 13/59 [22%] clinic), and in duration of postwithdrawal treatment by survival analysis. Most participants in both groups entered postwithdrawal buprenorphine maintenance. On an intention-to-treat basis, self-reported heroin use in the month before the Day 91 interview was significantly lower than at baseline (27 days/month at baseline, 14 days/month at Day 91; P < 0.001) and did not differ between groups. Buprenorphine detoxification in primary care was estimated to be $24 more expensive per patient than treatment at the clinic. The incremental cost-effectiveness ratio reveals that, in this context, it costs $20 to achieve a 1% improvement in outcome in primary care. Conclusions: Buprenorphine-assisted detoxification from heroin in specialist clinic and primary care settings had similar efficacy and cost-effectiveness. Buprenorphine treatment can be initiated safely in primary care settings by trained GPs.
Article
The Severity of Dependence Scale (SDS) was devised to provide a short, easily administered scale which can be used to measure the degree of dependence experienced by users of different types of drugs. The SDS contains five items, all of which are explicitly concerned with psychological components of dependence. These items are specifically concerned with impaired control over drug taking and with preoccupation and anxieties about drug use. The SDS was given to five samples of drug users in London and Sydney. The samples comprised users of heroin and users of cocaine in London, and users of amphetamines and methadone maintenance patients in Sydney. The SDS satisfies a number of criteria which indicate its suitability as a measure of dependence. All SDS items load significantly with a single factor, and the total SDS score was extremely highly correlated with the single factor score. The SDS score is related to behavioural patterns of drug taking that are, in themselves, indicators of dependence, such as dose, frequency of use, duration of use, daily use and degree of contact with other drug users; it also shows criterion validity in that drug users who have sought treatment at specialist and non-specialist agencies for drug problems have higher SDS scores than non-treatment samples. The psychometric properties of the scale were good in all five samples, despite being applied to primary users of different classes of drug, wing different recruitment procedures in different cities in different countries.
Article
There has been much speculation about the nature and extent of mortality among drug injectors in Glasgow. In order to determine injectors’ mortality rate and compare this rate to the general population, identifier information from 459 drug injectors who received treatment for drug misuse in Glasgow between 1982 and 1994 was linked to the Scottish Mortality Register. The average duration of follow-up from cohort entry was 5.5 years and 10.2 years from commencement of drug injection. By the end of 1994, 53 cohort members had died. The average annual mortality rate of 1.8% was the same as that observed in a London cohort followed-up from 1969 to 1991. However, the excess mortality ratio (EMR) of 22.0 was almost double the London rate (11.9) because of the much lower average age of mortality (26.3 vs. 3S.2 years). There was no significant time trend in EMR. Kaplan-Meier hazard analyses show that younger patients and those who were HIV positive had significantly elevated mortality rates. The main cause of death was overdose, although it is unclear how many were accidental and how many intentional. Three of the six fatalities among HIV positive injectors were AIDS related. This study enables the first realistic assessment of the hypothesis that drug-related deaths in Glasgow are especially high. In relation to other populations of drug injectors, the annual mortality rate is comparable, although the average age of mortality is much lower in Glasgow. Consequently, in comparison to the general population, the mortality rate of drug injectors is higher in Glasgow compared to other cities.
Article
This article presents a new instrument with which to assess the effects of opiate treatment. The Opiate Treatment Index (OTI) is multi-dimensional in structure, with scales measuring six independently measured outcome domains: drug use; HIV risk-taking behaviour; social functioning; criminality; health; and psychological adjustment. Psychometric properties of the Index are excellent, suggesting that the OTI is a relatively quick, efficient means of obtaining reliable and valid data on opiate users undergoing treatment over a range of relevant outcome domains.
Article
The mortality within a cohort of 115 street heroin addicts was studied for 5–8 years using the Kaplan-Meier survival estimate technique. This differed markedly from the relatively low mortality of 166 comparable heroin addicts given methadone maintenance treatment (MT). The street addicts’ mortality rate was 63 times that expected, compared with official statistics for a group of this age and sex distribution. When 53 patients in MT were involuntarily expelled from treatment, due to violation of programme rules, they returned to the high mortality of street addicts (55 times that expected). A group of 34 rehabilitated patients who left MT with medical consent retained the low mortality of MT patients (their mortality rate was 4 times that expected). Despite this great improvement in survival, even patients in MT showed a moderately elevated mortality (8 times that expected), mainly due to diseases acquired before entering the treatment programme. It is concluded that MT exerts a major improvement in the survival of heroin addicts.
Article
Objectives: To estimate the effects of methadone programs in New South Wales on mortality. DESIGN AND CASES: Retrospective, cross-sectional study of all 1994 New South Wales coronial cases in which methadone was detected in postmortem specimens taken from the deceased. Cases were people we identified as patients in NSW methadone maintenance programs or those whose deaths involved methadone syrup diverted from maintenance programs. Outcome measures: Relative risks of fatal, accidental drug toxicity in the first two weeks of treatment and later; the number of lives lost as a result of maintenance treatment; preadmission risks and the number of lives saved by maintenance programs, calculated from data from a previous study. Results: There was very close agreement between this study's classifications and official pathology reports of accidental drug toxicity. The relative risk (RR) of fatal accidental drug toxicity for patients in the first two weeks of methadone maintenance was 6.7 times that of heroin addicts not in treatment (95% CI RR, 3.3-13.9) and 97.8 times that of patients who had been in maintenance more than two weeks (95% CI RR, 36.7-260.5). Despite 10 people dying from iatrogenic methadone toxicity and diverted methadone syrup being involved in 26 fatalities. In 1994, NSW maintenance programs are estimated to have saved 68 lives (adjusted 95% CI, 29-128). Conclusions: In 1994, untoward events associated with NSW methadone programs cost 36 lives in NSW. To reduce this mortality, doctors should carefully assess and closely monitor patients being admitted to methadone maintenance and limit the use of takeaway doses of methadone.
Article
The Severity of Dependence Scale (SDS) was devised to provide a short, easily administered scab which can be used to measure the degree of dependence experienced by users of different types of drugs. The SDS contains five items, all of which are explicitly concerned with psychological components of dependence. These items are specifically concerned with impaired control over drug taking and with preoccupation and anxieties about drug use. The SDS was given to five samples of drug users in London and Sydney. The sampler comprised users of heroin and users of cocaine in London, and users of amphetamines and methadone maintenance patients in Sydney. The SDS satisfies a number of criteria which indicate its suitability as a measure of dependence. All SDS items load significantly with a single factor, and the total SDS score was extremely highly correlated with the single factor score. The SDS score is related to behavioural patterns of drug taking that are, in themselves, indicators of dependence, such as dose, frequently of use, duration of use, daily use and degree of contact with other drug users; it also shows criterion validity in that drug users who have sought treatment at specialist and non-specialist agencies for drug problems have higher SDS scores than non-treatment samples. The psychometric properties of the scale were good in all five samples, despite being applied to primary users of different classes of drug, using different recruitment procedures in different cities in different countries.
Article
The mortality within a cohort of 115 street heroin addicts was studied for 5-8 years using the Kaplan-Meier survival estimate technique. This differed markedly from the relatively low mortality of 166 comparable heroin addicts given methadone maintenance treatment (MT). The street addicts' mortality rate was 63 times that expected, compared with official statistics for a group of this age and sex distribution. When 53 patients in MT were involuntarily expelled from treatment, due to violation of programme rules, they returned to the high mortality of street addicts (55 times that expected). A group of 34 rehabilitated patients who left MT with medical consent retained the low mortality of MT patients (their mortality rate was 4 times that expected). Despite this great improvement in survival, even patients in MT showed a moderately elevated mortality (8 times that expected), mainly due to diseases acquired before entering the treatment programme. It is concluded that MT exerts a major improvement in the survival of heroin addicts.
Article
Data are presented on the 43 people who died over a 22-year follow-up period of a cohort of 128 heroin addicts drawn in 1969 from the newly opened London clinics. The main causes of death were drug-related, with 18 deaths specifically determined as due to overdose, of which the great majority were among people being prescribed opiates at the time. The mortality rate was a mean of 1.84% annually, and the excess mortality ratio was 11.9. This excess was highest at the beginning and varied over the period of study, appearing higher at the opening of the clinics and again in the mid-1980s. No sex differences in mortality rates were demonstrated but the excess mortality was concentrated at younger ages. No prediction of the 85 survivors could be made on the basis of length of heroin use prior to study intake, nor on age at intake.
Article
A long-term follow-up was made of a cohort of 307 heroin addicts admitted into a high-dose, Australian methadone maintenance programme in the early 1970s. Using data from clinic records, official death records and methadone treatment histories, it was found that subjects were nearly three times as likely to die outside of methadone maintenance as in it (95% CI RR 1.45 to 5.61). Data were further analyzed using Cox regression to investigate the association of maximum daily methadone dose and a change in clinic policy with retention in maintenance treatment. It is estimated that subjects given a maximum daily dose of 80 mg were nearly twice as likely to be discharged during the first three years of maintenance as those given 120 mg (95% CI RR 1.3 to 2.2). The estimated median time in maintenance for subjects given a maximum dose of 120 mg was 1150 days while for 80 mg it was 660 days. It is further estimated that the change in clinic policy from abstinence to indefinite maintenance reduced to one-third subjects' risk of leaving after three years' of treatment (95% CI RR 0.19 to 0.54). It is concluded that, in order to minimize heroin addicts' risk of death, they should be offered indefinite, high-dose methadone maintenance.
Article
There has been much speculation about the nature and extent of mortality among drug injectors in Glasgow. In order to determine injectors' mortality rate and compare this rate to the general population, identifier information from 459 drug injectors who received treatment for drug misuse in Glasgow between 1982 and 1994 was linked to the Scottish Mortality Register. The average duration of follow-up from cohort entry was 5.5 years and 10.2 years from commencement of drug injection. By the end of 1994, 53 cohort members had died. The average annual mortality rate of 1.8% was the same as that observed in a London cohort followed-up from 1969 to 1991. However, the excess mortality ratio (EMR) of 22.0 was almost double the London rate (11.9) because of the much lower average age of mortality (26.3 vs. 38.2 years). There was no significant time trend in EMR. Kaplan-Meier hazard analyzes show that younger patients and those who were HIV positive had significantly elevated mortality rates. The main cause of death was overdose, although it is unclear how many were accidental and how many intentional. Three of the six fatalities among HIV positive injectors were AIDS related. This study enables the first realistic assessment of the hypothesis that drug-related deaths in Glasgow are especially high. In relation to other populations of drug injectors, the annual mortality rate is comparable, although the average age of mortality is much lower in Glasgow. Consequently, in comparison to the general population, the mortality rate of drug injectors is higher in Glasgow compared to other cities.
Article
Mortality among 507 patients in a methadone program over a 1-year period was assessed. Mortality was determined for patients in treatment (n = 397), and 12 months later for those discharged (n = 110). Of discharged patients, 8.2% (9/110) had died, of which six were caused by heroin overdose. None of the discharged clients were in treatment at the time of death. All deaths were among clients who either dropped out of treatment or were discharged unfavorably from the program. Comparatively, only 1% (4/397) of patients died while enrolled in treatment. Death rates, especially overdose, are high among patients who are unfavorably discharged or drop out of methadone treatment. Efforts should be made to retain these at-risk patients in methadone treatment even though treatment response may be suboptimal.
Article
This study estimated future morbidity, mortality, and costs resulting from hepatitis C virus (HCV). We used a computer cohort simulation of the natural history of HCV in the US population. From the year 2010 through 2019, our model projected 165,900 deaths from chronic liver disease, 27,200 deaths from hepatocellular carcinoma, and $10.7 billion in direct medical expenditures for HCV. During this period, HCV may lead to 720,700 years of decompensated cirrhosis and hepatocellular carcinoma and to the loss of 1.83 million years of life in those younger than 65 at a societal cost of $21.3 and $54.2 billion, respectively. In sensitivity analysis, these estimates depended on (1) whether patients with HCV and normal transaminase levels develop progressive liver disease, (2) the extent of alcohol ingestion, and (3) the likelihood of dying from other causes related to the route of HCV acquisition. Our results confirm prior Centers for Disease Control and Prevention projections and suggest that HCV may lead to a substantial health and economic burden over the next 10 to 20 years.
Article
To determine whether buprenorphine is more effective than clonidine and other symptomatic medications in managing ambulatory heroin withdrawal. Open label, prospective randomized controlled trial examining withdrawal and 4-week postwithdrawal outcomes on intention-to-treat. Two specialist, out-patient drug treatment centres in inner city Melbourne and Sydney, Australia. One hundred and fourteen dependent heroin users were recruited. Participants were 18 years or over, and with no significant other drug dependence, medical or psychiatric conditions or recent methadone treatment. One hundred and one (89%) participants completed a day 8 research interview examining withdrawal outcomes, and 92 (81%) completed day 35 research interview examining postwithdrawal outcomes. Participants randomized to control (n = 56) (up to 8 days of clonidine and other symptomatic medications) or experimental (n = 58) (up to 5 days of buprenorphine) withdrawal groups. Following the 8-day withdrawal episode, participants could self-select from range of postwithdrawal options (naltrexone, substitution maintenance, or counselling). Retention in withdrawal; heroin use during withdrawal; and retention in drug treatment 4 weeks after withdrawal. Withdrawal severity; adverse events, and heroin use in the postwithdrawal period. The experimental group had better treatment retention at day 8 (86% versus 57%, P = 0.001, 95% CI for numbers needed to treat (NNT) = 3-8) and day 35 (62% versus 39%, P = 0.02, 95% CI for NNT = 4-18); used heroin on fewer days during the withdrawal programme (2.6 +/- 2.5 versus 4.5 +/- 2.3, P < 0.001, 95% CI = 1-2.5 days) and in the postwithdrawal period (9.0 +/- 8.2 versus 14.6 +/- 10, P < 0.01, 95% CI = 1.8-9.4); and reported less withdrawal severity. No severe adverse events reported. Buprenorphine is effective for short-term ambulatory heroin withdrawal, with greater retention, less heroin use and less withdrawal discomfort during withdrawal; and increased postwithdrawal treatment retention than symptomatic medications.
Article
To assess the efficacy of buprenorphine compared with methadone maintenance therapy for opioid dependence in a large sample using a flexible dosing regime and the marketed buprenorphine tablet. Patients were randomized to receive buprenorphine or methadone over a 13-week treatment period in a double-blind, double-dummy trial. Three methadone clinics in Australia. Four hundred and five opioid-dependent patients seeking treatment. Patients received buprenorphine or methadone as indicated clinically using a flexible dosage regime. During weeks 1-6, patients were dosed daily. From weeks 7-13, buprenorphine patients received double their week 6 dose on alternate days. Retention in treatment, and illicit opioid use as determined by urinalysis. Self-reported drug use, psychological functioning, HIV-risk behaviour, general health and subjective ratings were secondary outcomes. Intention-to-treat analyses revealed no significant difference in completion rates at 13 weeks. Methadone was superior to buprenorphine in time to termination over the 13-week period (Wald chi 2 = 4.371, df = 1, P = 0.037), but not separately for the single-day or alternate-day dosing phases. There were no significant between-group differences in morphine-positive urines, or in self-reported heroin or other illicit drug use. The majority (85%) of the buprenorphine patients transferred to alternate-day dosing were maintained in alternate-day dosing. Buprenorphine did not differ from methadone in its ability to suppress heroin use, but retained approximately 10% fewer patients. This poorer retention was due possibly to too-slow induction onto buprenorphine. For the majority of patients, buprenorphine can be administered on alternate days.
Article
To study the putative role of methadone maintenance treatment in the improvement of life expectancy of opioid addicts. Retrospective longitudinal study. Participants: All 1487 patients receiving methadone maintenance treatment in Alicante between June 1990 and December 1997. Mortality rates were studied using Kaplan-Meier survival curves. Protection or risk factors were analyzed using Cox's proportional hazards model. Mortality rates decreased from 87/1000 in 1991 to 17/1000 in 1997. The following factors influenced mortality: HIV infection [Hazard Ratio (HR)=7, 95% confidence interval (CI)=4-12]; current methadone status (HR=3.2, 95%CI=1.5-7.1) and MMT retention (retained vs. drop-out, HR=0.5, 95%CI=0.2-1.1; re-enrolled vs. drop-out, HR=0.3, 95%CI=0.2-0.5). Expediting entry and re-enrolling in methadone maintenance treatment improves survival.
Article
Buprenorphine was registered in Australia as a maintenance and detoxification agent for the management of opioid dependence in November, 2000, and became widely available in August, 2001. This paper provides an overview of key developments in the introduction of buprenorphine treatment in Australia, with an emphasis upon the delivery of services in community-based (primary care) settings. A central study in this work was the Buprenorphine Implementation Trial (BIT), a randomized, controlled trial comparing buprenorphine and methadone maintenance treatment delivered under naturalistic conditions by specialist and community-based service providers (general practitioners and community pharmacists) in 139 subjects across nineteen treatment sites. In addition to conventional patient outcome measures (treatment retention, drug use, psychosocial functioning, and cost effectiveness), the BIT study also involved the development and evaluation of clinical guidelines, training programs for clinicians, and client literature, which are described here. Integration of treatment systems (methadone with buprenorphine, specialist and primary-care programs) and factors thought to be important in the uptake of buprenorphine treatment in Australia since registration are discussed.
Article
To provide global estimates of the prevalence of injecting drug use (IDU) and HIV prevalence among IDU, in particular to provide estimates for developing and transitional countries. Collation and review of existing estimates of IDU prevalence and HIV prevalence from published and unpublished documents for the period 1998-2003. The strength of evidence for the information was assessed based on the source and type of study. Estimates of IDU prevalence were available for 130 countries. The number of IDU worldwide was estimated as approximately 13.2 million. Over ten million (78%) live in developing and transitional countries (Eastern Europe and Central Asia, 3.1 million; South and South-east Asia, 3.3 million; East-Asia and Pacific, 2.3 million). Estimates of HIV prevalence were available for 78 countries. HIV prevalence among IDU of over 20% was reported for at least one site in 25 countries and territories: Belarus, Estonia, Kazakhstan, Russia, Ukraine, Italy, Netherlands, Portugal, Serbia and Montenegro, Spain, Libya, India, Indonesia, Malaysia, Myanmar, Nepal, Thailand, Viet Nam, China, Argentina, Brazil, Uruguay, Puerto Rico, USA and Canada. These findings update previous assessments of the number of countries with IDU and HIV-infected IDU, and the previous quantitative global estimates of the prevalence of IDU. However, gaps remain in the information and the strength of the evidence often was weak.
Article
To assess the relationship between methadone treatment (MT) and overdose and HIV/AIDS mortality among heroin users resident in Barcelona city. All patients who started treatment in any treatment centre between 1992 and 1997 were included in a cohort the first time they were admitted for heroin addiction treatment. Follow-up controls were carried out every 9 months, on average, until 31 December 1999. Variables, both constant and varying over time, were fitted into Cox regression models. The study recruited 5049 patients, which provided 23,048.2 person-years. Fifty per cent were in MT during the study period; of the total cohort 1005 patients died: 38.4% due to AIDS, 34.7% to overdose and 27% to other causes. Overall mortality decreased from 5.9 deaths per 100 person-years in 1992 to 1.6 in 1999. Globally, life expectancy at birth was 39 years, 38 years lower than that of the general population. The main factor for overdose mortality was not being in MT at the time of death [relative ratio (RR) = 7.1]; other factors were being a current injector at baseline and being HIV positive. For AIDS mortality, the main factor was the calendar year (RR for 1996 versus 1999 = 4.6), the next major factor was more than 10 years of heroin consumption, followed by not being in MT, being unemployed, then having a prison record. The observed mortality decline could be linked to the effectiveness of low-threshold MT. The life expectancy of heroin users increased by 21 years during the study period.
Article
A study was undertaken to estimate the frequency of iatrogenic methadone toxicity in the first 2 weeks of maintenance treatment in NSW. Cases were identified from a list of all 1994 methadone-associated deaths using data on methadone patients held by the NSW and Queensland Health Departments. The likely causes of death were determined from data collected from coronial files. A forensic toxicologist experienced in the area gave an independent opinion. Of the 14 deaths in the first 2 weeks of maintenance, at least 10 were primarily caused by the toxic effects of methadone prescribed by NSW doctors. The rate of fatal iatrogenic methadone toxicity was 2.2 per thousand admissions to maintenance. Victims of fatal iatrogenic toxicity often displayed signs of methadone intoxication in the days before their death. They invariably died several hours after taking the fatal dose, usually after seeming to go to sleep. Often friends or family were concerned about their welfare, were unable to rouse them from their "sleep" and frequently reported the deceased was "snoring" loudly for some time before their demise. The author recommends that patients entering methadone maintenance should be informed of the risks and should be required to give written consent to treatment. To prevent fatal methadone toxicity, patients should receive daily medical assessment during the first 1-2 weeks of maintenance.
Article
To determine levels of systemic disease among cases of death due to opioid toxicity. Analysis of coronial cases. Sydney, Australia. A total of 841 cases of death due to opioid toxicity (1 January 1998-31 December 2002). Ventricular hypertrophy was present in 5.9% of cases and severe coronary artery atherosclerosis in 5.7%. Severe coronary pathology was more pronounced among older cases. Pre-existing bronchopneumonia was present in 13.2% of cases. Hepatic pathology was the most common type of pathology, and was far more marked among older cases. Cirrhosis was present in 25.3% of those aged > 44 years. Levels of renal pathology were comparatively low, but were related significantly to increasing age. Systemic disease in more than one organ system was present in 24.4% of cases, and was related to increasing age (44% of those aged > 44 years). The only pathology for which gender was an independent predictor among opioid cases was ventricular hypertrophy, more common in males. Systemic disease, most prominently liver disease, is common among fatal opioid toxicity cases, and may be a factor in understanding the dynamics and age demographics of opioid-related death.
Article
To estimate mortality rates among HIV-negative injecting drug users (IDUs) and non-injecting drug users (non-IDUs), and to assess predictors for mortality among the IDUs. Prospective cohort study in northern Thailand with 2-year follow-up. IDUs and non-IDUs who were admitted for detoxification treatment for opiate or amphetamine dependence in a regional drug treatment center were screened. After discharge, HIV-negative individuals were followed-up in the community. A total of 821 HIV-negative drug users [346 IDUs (42%) and 475 non-IDUs, median age = 32; 51% were ethnic minorities]. All-cause mortality. There were 33 deaths over 1360 person-years of follow-up. The all-cause mortality rate was 39 per 1000 person-years among IDUs [standardized mortality ratio (SMR) = 13.9], and was 14 per 1000 person-years among non-IDUs (SMR = 4.4). Among male IDUs, the hazards for all-cause deaths were ethnic minority status [adjusted hazard ratio (HR) = 2.9, 95% CI = 1.2-7.2], incident HIV infection (HR = 2.8, 95% CI = 1.1-7.7) and longer duration of drug injection (HR = 1.07, 95% CI = 1.01-1.14). The mortality among IDUs is high. Being from an ethnic minority, recent HIV acquisition, and a greater number of years of drug injection are predictors of mortality among the IDUs in this region.
Article
The aim of this study was to compare the mortality associated with oral naltrexone, methadone and buprenorphine in opioid dependence treatment, employing a retrospective data analysis using coronial and prescription data. The number of deaths were identified through national coronial data and number of treatment recipients were estimated from 2000 to 2003 prescriptions and restricted medications data. Mortality rates were expressed as deaths per number of treatment episodes and per person-years at high and low risk of fatal opioid overdose. Thirty-two oral naltrexone, one buprenorphine and 282 methadone-related deaths were identified. Mortality rates in the highest risk period in deaths per 100 person-years were 22.1 (14.6 - 32.2) for oral naltrexone following treatment cessation and 3.0 (2.3 - 3.9) for methadone during treatment induction. Rates in the lowest risk period in deaths per 100 person-years were 1.0 (0.3 - 2.2) during oral naltrexone treatment and 0.34 (0.3 - 0.4) during post-induction methadone treatment. The relative risk of death for oral naltrexone subjects was 7.4 times (high-risk period, p < 0.0001) or 2.8 times (low-risk period, p = 0.055) that of methadone subjects. This is the first comparison of mortality associated with these three pharmacotherapies for opioid dependence. The risk of death related to oral naltrexone appears higher than that related to methadone treatment.
Estimating future hepatitis C morbidity, mortality and costs in the United States 468 Amy Gibson et al. © 2008 The Authors Journal compilation © 2008 Society for the Study of Addiction Addiction
  • J B Wong
  • G M Mcquillan
  • J G Mchutchison
  • Poynard
Wong J. B., McQuillan G. M., McHutchison J. G., Poynard T