Tailoring opioid substitution therapy: Patient profiles, clinical outcomes, and preferences for new formulations.

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

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

Heroin addiction is a significant health and social problem in England, and considerable investment has been made in treatment services in the past 10 years. Central Government funding for drug...

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessCould Addiction-Fighting Tool Be in Palm of Your Hand?Joan Arehart-TreichelJoan Arehart-TreichelSearch for more papers by this authorPublished Online:6 Feb 2009https://doi.org/10.1176/pn.44.3.0016aFancy this: opiate abusers who want to kick their habit can click on their Palm Pilot (or any other handheld, digital communications device) whenever they feel the urge to relapse, and the electronic device will quickly provide them with information to help them resist the craving.Such on-the-spot feedback intervention may sound scientifically improbable. But a study reported in the January Archives of General Psychiatry suggests that it might eventually become a reality.David Epstein, Ph.D., a staff scientist at the National Institute on Drug Abuse's Intramural Research Program in Baltimore, and colleagues conducted this study. A total of 102 individuals who were being given methadone to counter their heroin addiction agreed to serve as subjects.Subjects were given a palmtop computer and asked to enter information into it whenever they felt tempted to use heroin or cocaine, or whenever they actually used either heroin or cocaine. (Although methadone is highly effective in countering heroin use, it is not always a cure-all, and it has no impact on cocaine use.) They were asked to make written entries into the device describing what mood they were in, where they were, whom they were with, and what they were doing. To enhance accuracy of reporting, subjects were assured that the information they provided would be kept confidential.The subjects provided daily entries anywhere from six days to 189 days, which, in total, added up to almost 15,000 person-days.“The first thing that struck us—I won't call it a surprise, but I will say it was a pleasure to see—was the orderly quality of the data,” Epstein told Psychiatric News. “In a scientific sense, this was a high-risk study. No one had ever asked 102 cocaine and heroin users to walk around all day with palmtop computers and report on their moods and activities, so there was always the possibility that the responses would be perfunctory and haphazard, leaving us with little or nothing to analyze. When we saw the results, we knew that our participants had taken the study seriously.”Epstein and his group then used the data to see what types of moods preceded subjects' urges to use heroin or cocaine or their use of these substances.“The main thing we can say from these analyses is that the harbingers of cocaine craving and use were not quite the same as the harbingers of heroin craving and use,” Epstein said. “I don't think anyone could have guessed in advance the pattern of differences we found.” For example, although negative emotions such as feeling sad, angry, worried, or down after being criticized by others tended to precede heroin craving or use, those types of emotions were not the only catalysts to precede cocaine craving or use; just being in a good mood could be the trigger for cocaine abusers.The researchers will analyze the data to learn what types of locations, companions, or activities preceded the subjects' urges to use heroin or cocaine or their relapses into using these drugs. It might then be possible to design a palmtop-computer program to help individuals handle moods or situations that tend to trigger craving or use of these drugs.“That sort of on-the-spot feedback intervention is already a reality for several kinds of behavioral problems—at the level of clinical trials anyway,” Epstein noted. “A person with, say, generalized anxiety disorder can put information into a palmtop computer during an acute episode of anxiety, and the palmtop can respond by giving relaxation exercises or generating suggestions for cognitively reframing the situation.... A more ambitious intervention would be to have the palmtop learn, over time, what constitutes a risky pattern of behavior for the person using it and to tailor the feedback on that basis.”The study was funded by the Intramural Research Program of the National Institute on Drug Abuse.An abstract of “Real-Time Electronic Diary Reports of Cue Exposure and Mood in the Hours Before Cocaine and Heroin Craving and Use” is posted at<http://archpsyc.ama-assn.org/cgi/content/short/66/1/88>.▪ ISSUES NewArchived

The aims of this study were to determine the prevalence of methadone syrup injecting in Adelaide, South Australia and to characterize methadone injectors, including their heroin use and risk behaviours associated with heroin overdose. Cross-sectional design. Community setting, principally metropolitan Adelaide. Current heroin users (used heroin in the last 6 months), recruited through snowballing. Structured questionnaire. Of 365 participants, 18.4% reported having ever injected methadone syrup and 11.0% had injected methadone in the last 6 months. Those that had injected methadone were more likely to be male, and were more likely to be receiving methadone maintenance. They were also maintained on higher doses of methadone than subjects not injecting methadone. A history of methadone injection was associated with more heroin overdose experiences and greater dependence on heroin. Methadone injectors were also more likely to engage in risky behaviours associated with heroin overdose, including using heroin when no other people were present, not trial-tasting new batches of heroin and polydrug use. Methadone syrup injectors appear to be at greater risk of a series of harms than subjects not injecting methadone. The prevalence of methadone syrup injecting in Adelaide, South Australia was 11%, which was lower than prevalence in Sydney, New South Wales, but higher than in Melbourne, Victoria. Jurisdictional differences concerning the prevalence of methadone syrup injecting may reflect differing policies by each state to methadone dispensing.

Several alternative indicators are currently available to researchers, policy makers, and practitioners for gauging levels and patterns of illicit drug use within and across communities. Yet there exists little information that allows reliable comparisons across indicators to determine whether they tell essentially the same story about variation in the prevalence of drug use. In particular, it remains unclear how closely arrest statistics, the leading law enforcement indicator of illicit drug use, correspond to other law enforcement indicators, such as urine tests of jail inmates, or to public health measures, such as emergency departments' and medical examiners' reports. In this paper we assess the relationships between alternative law enforcement and public health indicators of cocaine, heroin, and marijuana use for a sample of large U.S. cities. We find pronounced convergence across measurement systems in cocaine and heroin use, but little convergence for marijuana use. In addition to other research and policy implications, these results increase confidence in the use of arrest data to assess variation across urban areas in cocaine and heroin use.

Is inhalant use a risk factor for heroin and injection drug use among adolescents in the United States?

Cognitive behavioral therapy for adherence and depression (CBT-AD) in HIV improves both adherence and depression outcomes relative to enhanced treatment as usual (ETAU). However, in persons with injection drug use (PWIDU) histories, adherence gains seen during treatment have not been maintained postintervention. Therefore, we examined whether heroin or cocaine use at study entry moderated acquisition or maintenance of adherence gains after CBT-AD. HIV-positive adults in treatment for opioid dependence (n = 89) were randomly assigned to CBT-AD or ETAU and completed 3-, 6-, and 12-month assessments. Participants were majority male (61%), white (48%), and heterosexual (79%). Hierarchical linear modeling was used to evaluate whether heroin or cocaine use at baseline interacted with intervention assignment to predict change in adherence during active treatment and follow-up. CBT-AD-related improvement in adherence during the active intervention period did not vary by baseline substance use. However, cocaine use (but not heroin use) at baseline interacted with intervention assignment to predict a significant decline in follow-up adherence (cocaine use × group condition coefficient = -0.77, t = -2.44, p = 0.02) such that by 12 months, adherence among CBT participants was significantly lower among those who used cocaine (45.0%) compared to those who did not (72.3%; t = 2.50, p = 0.018). HIV-positive PWIDU who use heroin or cocaine at baseline can benefit from the CBT-AD intervention to improve adherence to antiretroviral therapy; therefore, providers should not withhold an active psychosocial treatment for HIV-positive PWIDU who are using. Cocaine use at baseline may limit the degree to which gains are maintained postintervention, and therefore, booster sessions may be needed.

Background: Non-prescribed substance use (NPSU) during the treatment of opioid use disorder (OUD) is a recognized phenomenon. The use of non-prescribed substances is associated with discontinuing treatment and drop-out can occur within the early weeks of treatment, before benefit from treatment occurs. Recent developments in treatment include long-acting, slow-release depot buprenorphine injections. This article focuses on NPSU during the first month of treatment with depot buprenorphine, addressing the frequency with which it occurs, the substances used, and reasons for use. Methods: 70 semi-structured interviews (held at three time-points) were conducted with 26 patients initiating depot buprenorphine as part of a longitudinal qualitative study. Analysis prioritized content and framework analyses. Findings: 17/26 participants self-reported NPSU at various times during the first month of treatment. NPSU typically involved heroin, crack-cocaine and some use of benzodiazepines and/or cannabis. Participants’ reasons for heroin use were connected to their subjective accounts of opioid withdrawal symptoms, the management of pain, and experimentation (to test the blockade effect of buprenorphine). Frequency of heroin use was typically episodic rather than sustained. Participants associated crack-cocaine use with stimulant-craving and social connections, and considered their use of this substance to be difficult to manage. Conclusions: Patients’ initial engagement with treatment for OUD is rarely examined in qualitative research. This study highlights how NPSU amongst patients receiving new forms of such treatment continues to be a challenge. As such, shared decision-making (between providers and patients) regarding treatment goals and NPSU should be central to the delivery of depot buprenorphine treatment programmes.

Several studies have shown alterations in different components of executive functioning in users of different drugs, including cannabis, cocaine and heroin. However, it is difficult to establish a specific association between the use of each of these drugs and executive alterations, since most drug abusers are polysubstance abusers, and alcohol is a ubiquitous confounding factor. Moreover, in order to study the association between consumption of different drugs and executive functioning, the patterns of quantity and duration of drugs used must be considered, given the association between these parameters and the executive functioning alteration degree. Based on the multicomponent approach to executive functions, the aims of the present study were: (i) to analyse the differential contribution of alcohol versus cocaine, heroin and cannabis use on executive functions performance; and (ii) to analyse the contribution made by the severity of the different drugs used (quantity and duration patterns) on these functions in a sample of polysubstance abusers that requested treatment for cannabis-, cocaine- or heroin-related problems. We administered measures of fluency, working memory, analogical reasoning, interference, cognitive flexibility, decision-making and self-regulation to two groups: 60 substance-dependent individuals (SDIs) and 30 healthy control individuals (HCIs). SDIs had significantly poorer performance than HCIs across all of the executive domains assessed. Results from hierarchical regression models showed the existence of common correlates of the use of alcohol, cannabis and cocaine on verbal fluency and decision-making; common correlates of quantity of cannabis and cocaine use on verbal working memory and analogical reasoning; common correlates of duration of cocaine and heroin use on shifting; and specific effects of duration of cocaine use on inhibition measures. These findings indicate that alcohol abuse is negatively associated with fluency and decision-making deficits, whereas the different drugs motivating treatment have both generalized and specific deleterious effects on different executive components.

The authors studied the use of heroin, marijuana, and cocaine before the onset of a first seizure in 308 patients with seizures and 294 controls at Harlem Hospital Center, New York City, between 1981 and 1984. Heroin use, both past and present, appeared to be a risk factor for all first seizures (adjusted odds ratio = 2.80, 95% confidence interval (CI) 1.53-5.74). For unprovoked seizures, the adjusted odds ratio was 2.58 (95% CI 1.36-4.90) for ever heroin use and 4.70 (95% CI 0.86-25.78) for heroin use within 24 hours of hospitalization. For provoked seizures, respective adjusted odds ratios were 3.65 (95% CI 1.54-8.65) and 27.74 (95% CI 3.57-215.52). Marijuana use appeared to be a protective factor against first seizures in men. For men with unprovoked seizures, the adjusted odds ratio was 0.42 (95% CI 0.22-0.82) for ever marijuana use and 0.36 (95% CI 0.18-0.74) for marijuana use within 90 days of hospitalization. For men with provoked seizures, respective adjusted odds ratios were 1.03 (95% CI 0.36-2.89) and 0.18 (95% CI 0.04-0.84). Cocaine use, while common among study subjects, was not shown to be a significant risk factor either for all first seizures or for subgroups of seizures, regardless of the time of last use. The authors conclude that heroin use is a risk factor and marijuana use a protective factor for new-onset seizures.

Heroin-Assisted Treatment Helps Some Patients

Introduction: People with substance use disorder (SUD) may be at increased risk of COVID-19 infection. However, there is little evidence regarding the incidence of and determinants associated with infection in this group. The aims of the study were to determine the cumulative incidence of COVID-19 among people who sought treatment for heroin, cocaine, cannabis, and alcohol use disorder in Catalonia; to identify sociodemographic, substance, and clinical determinants associated with COVID-19 infection among SUD patients; and to compare the cumulative incidence of COVID-19 infection in the population with SUD with that of the general population. Methods: A patient-based retrospective observational study was conducted. The study population comprised people who sought treatment for heroin, cocaine, cannabis, or alcohol use disorder in Catalonia in 2018 and 2019. We analysed cumulative incidence of COVID-19 (confirmed by PCR test) from 25 February to 31 December 2020. Additionally, we used a log-link binomial generalized linear model for COVID-19 infection, using the substance as the exposition, adjusting for sociodemographic and clinical variables. Results: Of the 23,092 individuals who sought treatment for SUD, 38.15% were considered suspected cases of COVID-19, and 2.60% (95% CI = 2.41–2.82) were confirmed positive for COVID-19 by PCR test during the study period. Those who sought treatment for alcohol use (cumulative incidence of COVID-19 of 3% [95% CI = 2.70–3.34]) had a higher risk ratio than, those who sought treatment for heroin use (cumulative incidence of 1.94% [95% CI = 1.47–2.56]). Being born outside of Spain, living in an institutionalized residence, having HIV, and being in a high morbidity group were associated with higher risk of COVID-19 infection. Meanwhile, the cumulative incidence of COVID-19 in the general population, according to public COVID-19 test data, was 3.86% (95% CI = 3.85–3.87). Conclusion: This study did not find higher cumulative incidence of COVID-19 infection among people with SUD in Catalonia in 2020, despite the clinical vulnerability of this population and their social disadvantage. However, differences were seen in the cumulative incidence of COVID-19 according to the substance for which treatment was sought. For example, those with alcohol dependence had a higher rate than those dependent on heroin. Further studies are needed to determine the factors contributing to these differences.

Hardcore drug users claim to be occasional users: drug use frequency underreporting

Research on the effects of cannabis on the brain and behavior has been surprisingly scarce. In humans, laboratory studies document toxicity and psychoactive effects of cannabinoids. However, among substance abuse patients, only a few studies have prospectively examined the relationship of cannabis use to remission or relapse of use of other substances. Because cannabis is a widely used substance, the authors examined whether cannabis use during follow-up after discharge from inpatient treatment affected cocaine, alcohol, and/or heroin use. Two hundred fifty patients 18 years old or older from an inpatient psychiatric/substance abuse setting participated in a Psychiatric Research Interview for Substance and Mental Disorders. All patients were diagnosed according to DSM-IV as having current alcohol, cocaine, and/or heroin dependence. Sustained remission was defined as at least 26 weeks without use following hospital discharge. Data were analyzed with Cox proportional hazards models. About one-third of the patients (N=73) used cannabis after hospital discharge. Postdischarge cannabis use substantially and significantly increased the hazard of first use of any substance and strongly reduced the likelihood of stable remission from use of any substance. Examination of specific substances indicated that cannabis use affected first use of alcohol, stable remission, and subsequent relapse of alcohol use as well as first use of cocaine and stable remission but was unrelated to heroin outcomes. Potential negative clinical implications of cannabis use should be considered when treating dependence on other substances and planning aftercare. Clinical and laboratory research is needed to provide understanding of the mechanisms of cannabinoids in relapse to alcohol and cocaine use.