[Show abstract][Hide abstract] ABSTRACT: Cocaine use continues to be a public health problem, yet there is no proven effective pharmacotherapy for cocaine dependence. A promising approach to treating cocaine dependence may be agonist-replacement therapy, which is already used effectively in the treatment of opioid and tobacco dependence. The replacement approach for cocaine dependence posits that administration of a long-acting stimulant medication should normalize the neurochemical and behavioral perturbations resulting from chronic cocaine use. One potential medication to be substituted for cocaine is methylphenidate (MPH), as this stimulant possesses pharmacobehavioral properties similar to those of cocaine.
To provide a qualitative review addressing the rationale for the use of MPH as a cocaine substitute and its clinical potential in the treatment of cocaine dependence.
We searched MEDLINE for clinical studies using MPH in patients with cocaine abuse/dependence and screened the bibliographies of the articles found for pertinent literature.
MPH, like cocaine, increases synaptic dopamine by inhibiting dopamine reuptake. The discriminative properties, reinforcing potential, and subjective effects of MPH and cocaine are almost identical and, importantly, MPH has been found to substitute for cocaine in animals and human volunteers under laboratory conditions. When taken orally in therapeutic doses, its abuse liability, however, appears low, which is especially true for extended-release MPH preparations. Though there are promising data in the literature, mainly from case reports and open-label studies, the results of randomized controlled trials have been disappointing so far and do not corroborate the use of MPH as a substitute for cocaine dependence in patients without attention deficit hyperactivity disorder.
Clinical studies evaluating MPH substitution for cocaine dependence have provided inconsistent findings. However, the negative findings may be explained by specific study characteristics, among them dosing, duration of treatment, or sample size. This needs to be considered when discussing the potential of MPH as replacement therapy for cocaine dependence. Finally, based on the results, we suggest possible directions for future research.
[Show abstract][Hide abstract] ABSTRACT: Das Injizieren psychotroper Substanzen in die Leistenvene ist mit einem hohen Risiko von Komplikationen verbunden, wird jedoch ver- gleichsweise häufig von Menschen angewandt, die das rasche Anfluten einer Substanz suchen. Der Umgang mit diesem Phänomen in der heroingestützten Behandlung (HegeBe) ist uneinheitlich und konfrontiert die Behandelnden mit ethischen und schadensmindernden Aspek- ten. In diesem Artikel werden neben einem Überblick über die einschlägige Literatur Vorkommen und Umstände des Leistenkonsums bei Patienten in heroingestützter Behandlung am Beispiel der Behandlungsstelle Janus in Basel beschrieben. Es wird ein Vorschlag entwickelt, um diesem Phänomen in der heroingestützten Behandlung strukturiert zu begegnen und dabei Schadensminderung und Sicherheit gleichermaßen zu berücksichtigen.
[Femoral injecting (i. e. “groin injecting”) of psychoactive substances is associated with a range of negative sequelae. Nevertheless substance users searching for a rapid onset of effect often apply this practice. The management of this phenomenon in heroin assisted treatment is inconsistent and confronts providers with aspects related to ethics and harm reduction. This article gives an overview of the literature on this topic and the prevalence and circumstances of this behavior. An approach for managing this phenomenon in heroin assisted treatment with regards to both saftey and harm reduction is suggested.]
[Show abstract][Hide abstract] ABSTRACT: Abstract
Concomitant cocaine use is a major problem in clinical practice in methadone maintenance treatment (MMT) and may interfere with successful treatment. Data from European methadone populations is sparse. This register-based study sought to explore the association between prescribed methadone dose and concomitant cocaine and heroin use in the methadone population of Basel City.
The study included 613 methadone patients between April 1, 2003 and March 31, 2004. Anonymized data was taken from the methadone register of Basel City. For analysis of the prescribed methadone dose distribution, the patient sample was split into three methadone dosage groups: a low dose group (LDG) (n = 200; < 60 mg/day), a medium dose group (MDG) (n = 273; 60 to 100 mg/day), and a high dose group (HDG) (n = 140; > 100 mg/day). Concomitant drug use was based on self-report.
Analysis showed a significant difference in self-reported cocaine use between groups (p < 0.001). Patients in the LDG reported significantly fewer cocaine consumption days compared to the MDG (p < 0.001) and the HDG (p < 0.05). Patients in the HDG reported significantly fewer heroin consumption days than those in the LDG (p < 0.01) and the MDG (p < 0.001). In logistic regression analysis, cocaine use was significantly associated with heroin use (OR 4.9).
Cocaine use in methadone patients may be associated with heroin use, which indicates the importance of prescribing appropriate methadone dosages in order to indirectly reduce cocaine use.
Full-text · Article · Dec 2014 · Substance Abuse Treatment Prevention and Policy
[Show abstract][Hide abstract] ABSTRACT: Background
Electronic dispensers for polypharmacy are used in home care to assist patients with their medication management and to improve adherence. Opioid dependent patients with substitution therapy often exhibit multiple risk factors for non-adherence. The increase of both the age and associated comorbidities in this population demand for innovative solutions to optimize medication management. We developed a novel medication supply model with an automated electronic medication dispenser to simultaneously assist opioid dependent patients with their medication and objectively monitor their adherence.
To evaluate the operational feasibility and resource feasibility of the novel supply model.
Two patients with unmet clinical outcomes due to suspected non-adherence were recruited from an outpatient addiction treatment clinic in Basel, Switzerland. With the novel model, opioid substitution treatment was provided at the clinic, while all other daily medication was supplied in unit-dose pouches with an automated electronic dispenser located at the patient’s home. We calculated adherence (taking and timing) and time needed for operation (production of the pouches, refilling of the dispenser, and support).
Between July 2013 and June 2014, patient A (male, 50 years, 6 tablets daily at 12 am) and patient B (female, 46 years, 5-6 tablets daily at 8 pm) were monitored for 337 and 273 days, respectively, with refill of the dispensers every 3 weeks. Patient A / B retrieved 96.4% / 97.4% of the pouches within 1 hour from the scheduled time. The remaining pouches were either dispensed later (1.8% / 0%), as pocket dose before the scheduled time (0.3% / 1.2%) or not at all (1.5% / 1.5%). Per refill, the mean time spent on production of the pouches was 28 minutes (41%), on travel 30 minutes (44%), on refilling the dispenser at the patient’s home 7 minutes (11%), and on support 2 minutes (4%).
Operational feasibility of the novel supply model was given by continuous medication supply and timing adherence to polypharmacy of more than 95%. Resource feasibility was acceptable with an effort of 1.5 hours every 3 weeks. Based on these preliminary results, a pilot study with 10 patients will be conducted to assess direct and indirect effects (adherence, clinical and humanistic outcomes, cost-effectiveness) and acceptance.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND:
Cocaine has become one of the drugs of most concern in Switzerland, being associated with a wide range of medical, psychiatric and social problems. Available treatment options for cocaine dependence are rare. The study sought to compare combined prize-based contingency management (prizeCM) plus cognitive-behavioral therapy (CBT) to CBT alone in cocaine-dependent patients.
Sixty cocaine-dependent patients participated in a randomized, controlled trial with two treatment conditions. The participants were randomly assigned to the experimental group (EG; n=29), who received CBT combined with prizeCM, or to the control group (CG; n=31), who received CBT only during 24 weeks. The primary outcome measures were retention, at least 3 consecutive weeks of cocaine abstinence, the maximum number of consecutive weeks of abstinence and proportions of cocaine-free urine samples during the entire 24-week and at 6-month follow-up.
Sixty-three percent of the participants completed the study protocol. Participants in both groups significantly reduced cocaine use over time. Overall, no difference in cocaine-free urine screens was found across the two treatment groups, except at weeks 8, 9, 10, 17 and 21 in favor of the EG.
The addition of prizeCM to CBT seems to enhance treatment effects, especially in the early treatment period, supporting results from previous studies. Both the combined intervention and CBT alone, led to significant reductions in cocaine use during treatment and these effects were sustained at 6-month follow-up. These findings underline the importance in implementing CM and CBT interventions as treatment options for cocaine dependence in the European context.
Full-text · Article · Oct 2014 · Drug and Alcohol Dependence
[Show abstract][Hide abstract] ABSTRACT: Benzodiazepine (BZD) use is widespread among opioid-maintained patients worldwide. We conducted a cross-sectional survey to investigate motives and patterns of BZD use and psychiatric comorbidity in a convenience sample of patients (n=193) maintained on oral opioid agonists or diacetylmorphine (DAM). Prolonged BZD use and high-risk behaviors like parenteral use were common. After principal component analysis, motives were divided into those related to negative affect regulation, positive affect regulation (i.e. reward-seeking) and somato-medical problems. Negative affect regulation and somato-medical motives were associated with prolonged use. Psychiatric comorbidity was associated with several self-therapeutic motives, most importantly to lose anxiety. Patients maintained on DAM were more likely to be ex-users of BZD and report high positive affect regulation. Therefore, patients maintained on different agonists may have deviating motives for BZD use, which could be of importance when addressing this issue. Treatment of psychiatric comorbidity, in particular anxiety, depressive and sleeping disorders, may be helpful in reducing BZD use, particularly in patients maintained on oral opioids.
No preview · Article · May 2013 · Addictive behaviors
[Show abstract][Hide abstract] ABSTRACT: Cocaine dependence has proved difficult to treat, whether it occurs alone or in combination with opiate dependence. No intervention has been demonstrated to be uniquely effective. Patients might benefit most from combined pharmacotherapeutic and psychotherapeutic interventions. The present study sought to evaluate the feasibility, tolerability, and efficacy of methylphenidate (MP) and cognitive-behavioral group therapy (CBGT) for cocaine dependence in diacetylmorphine-maintained patients. Sixty-two cocaine-dependent diacetylmorphine-maintained patients participated in a dual-site, double-blind, placebo-controlled pilot trial with 4 treatment conditions. The participants were randomly assigned to receive MP or a placebo each combined with either CBGT or treatment as usual for 12 weeks. Methylphenidate 30 mg and a placebo in identical capsules were administered onsite twice daily under supervision in a fixed-dose regimen without titration. Manual-guided CBGT consisted of 12 weekly sessions. Participation in the CBGT sessions was voluntary. Primary outcome measures were retention in pharmacologic treatment, cocaine-free urine samples, self-reported cocaine use, and adverse effects. Urine screens were performed thrice weekly. Seventy-one percent of the participants completed the study protocol. Methylphenidate was well tolerated with similar retention rates compared with the placebo. No serious adverse effects occurred. No difference in cocaine-free urine screens was found across the 4 treatment groups. Self-reported cocaine use was reduced in all 4 study groups. Methylphenidate and CBGT did not provide an advantage over a placebo or treatment as usual in reducing cocaine use. There were no signs of additive benefits of MP and CBGT. Because of the small sample size, the results are preliminary.
No preview · Article · Dec 2012 · Journal of clinical psychopharmacology
[Show abstract][Hide abstract] ABSTRACT: Seit Jahren ist der Kokainkonsum unter Opiatabhängigen verbreitet und stellt auch in opioidgestützten Behandlungen ein Problem dar. Bislang gibt es keine effektive Pharmakotherapie. Eine vielversprechende Behandlungsform ist die kognitiv-behaviorale Therapie. Die vorliegende randomisierte kontrollierte Pilotstudie mit vier Armen hat bei 62 kokainabhängigen Personen aus einer heroingestützten Behandlung placebokontrolliert und doppelblind die Einsatzmöglichkeit von Methylphenidat (MP) mit und ohne kognitiv-behaviorale Gruppentherapie (CBT) untersucht. Primäre Zielvariablen waren das Verbleiben in der medikamentösen Behandlung, der Kokainkonsum und unerwünschte Ereignisse. Die Studie wurde in zwei Zentren durchgeführt. Nach einer umfassenden Basiserhebung wurden die Versuchspersonen über zwölf Wochen entsprechend der Zufallszuteilung behandelt (MP oder Placebo, jeweils mit oder ohne CBT). Die Studienmedikation (30 mg MP oder Placebo) wurde zweimal täglich unter Aufsicht eingenommen. Die manualisierten Gruppentherapien wurden einmal pro Woche durchgeführt, die Teilnahme war freiwillig. Die Zielvariablen wurden regelmässig mit Befragungen und Urinproben erfasst. Die Datenanalyse erfolgte nach dem „Intent-to-treat-Prinzip“, wobei neben herkömmlichen statistischen Verfahren auch Multilevel-Modelle (GEE) gerechnet wurden. Von der Stichprobe verblieben 71% über zwölf Wochen in der Studie. Die Medikation wurde insgesamt gut toleriert. Die Studie lieferte keine Hinweise dafür, dass MP und/oder CBT in diesem Kollektiv den Kokainkonsum reduzieren. Die CBT besitzt für die Zukunft aber dennoch Potenzial.
[Show abstract][Hide abstract] ABSTRACT: Benzodiazepine (BZD) misuse in opioid-maintained patients is widespread and has been related to poorer treatment success. Associated factors, in particular, traumatic childhood experiences, have not been investigated extensively.
Cross-sectional survey including the childhood trauma questionnaire (CTQ) and clinical data among 193 patients prescribed oral opioids or injectable diacetylmorphine for opioid dependence.
BZD use was prevalent (61%) and the burden of childhood traumatic experiences was high with 67% reporting at least one trauma subscore of moderate-to-severe level. In univariate analysis, CTQ-subcategories "emotional abuse" (p<0.05), "emotional neglect" (p<0.01) and "physical neglect" (p<0.001) were significantly associated with prolonged BZD use. In multivariate analysis, prolonged BZD use was associated with categorized overall CTQ-scores (OR 1.5), HCV-seropositivity (OR 4.0), psychiatric family history (OR 2.3), and opioid dose (mg methadone equivalents, OR 1.010).
Childhood traumatic experiences may be associated with prolonged BZD use in opioid-maintained patients and could pose an important starting-point for prevention.
Full-text · Article · Jun 2011 · Drug and alcohol dependence
[Show abstract][Hide abstract] ABSTRACT: Heavy alcohol consumption may accelerate the progression of hepatitis C-related liver disease and/or limit efforts at antiviral treatment in opioid-dependent patients receiving heroin-assisted treatment (HAT). Our study aims to assess alcohol intake among HAT patients by self-reports compared to direct ethanol metabolites.
Fifty-four patients in HAT were recruited from the centre for HAT at the University of Basel, Switzerland. The patients completed the Alcohol Use Disorder Identification Test (AUDIT), a self-report questionnaire on past-week ethanol intake and provided samples for the determination of ethyl glucuronide (UEtG) and ethyl sulphate (UEtS) in urine and of ethyl glucuronide (HEtG) in hair.
Eighteen patients scored above the AUDIT cut-off levels. Twenty-six patients tested positive for UEtG and 29 for UEtS. HEtG identified ethanol intake of more than 20 g/d in 20 additional cases that did not appear in the AUDIT. Using the total score of the AUDIT, HEtG detected 14 additional cases of relevant alcohol intake.
The findings of this study, which is the first assessing alcohol intake in HAT patients using direct ethanol metabolites and self reports, suggest the complementary use of both. Improved detection of hazardous or harmful alcohol consumption in the context of HCV and heroin dependence will allow for earlier intervention in this population. This ultimately will contribute to an improvement in quality of life of patients in HAT. Furthermore, a significant reduction of costs can be achieved through a reduction of complications caused by alcohol intake.
No preview · Article · Dec 2010 · Drug and alcohol dependence
[Show abstract][Hide abstract] ABSTRACT: Some patients on steady-state methadone occasionally crave for extra opioids for different reasons (eg, cue-elicited craving, stress). This study examined the acute-on-chronic effects on heroin craving, mood, and opioid-like symptoms of a single, extra half-dose on top of the patient's prescribed daily methadone dosage. A randomized, double-blind, placebo-controlled, counterbalanced crossover design was used to test the safety of this practice and the hypotheses that extra methadone would reduce heroin craving and improve mood, with greater responses in lower-dose (20-60 mg/d) as compared with higher-dose patients (80-120 mg/d). Fourteen stabilized methadone-maintained volunteers of each dose group were examined predrug and postdrug on 2 separate days using a range of self-report measures (Heroin Craving Questionnaire, visual analogs, Befindlichkeits-Skala, Short Opiate Withdrawal Scale, and Opioid Agonist Scale). Additionally, patients' expectations and guesses regarding treatment were assessed predrug and postdrug, respectively. No adverse effects occurred after extra methadone. Participants could not reliably distinguish between extra methadone and placebo. Repeated-measures analyses of variance showed no effects of extra methadone on heroin craving and opioid agonist effects. However, extra methadone improved mood on the Befindlichkeits-Skala (F1/24 = 4.71, P = 0.04), with marginally greater effects in lower-dose patients ((F1/24 = 2.94, P = 0.099). A single 50% extra methadone dose is most likely safe in patients on stable methadone doses of 20 to 120 mg/d and may improve patients' mood. Extra methadone may constitute an important factor in the attractiveness of maintenance treatment and may enhance treatment outcome.
No preview · Article · Aug 2010 · Journal of clinical psychopharmacology