The characteristics of heroin users entering treatment: findings from the Australian treatment outcome study (ATOS)

The current study aimed to describe the characteristics (demographics, drug use, mental and physical health) of entrants to treatment for heroin dependence in three treatment modalities; and to compare these characteristics with heroin users not in or seeking treatment. Participants were 825 current heroin users recruited from Sydney, Adelaide and Melbourne: 277 entering methadone/buprenorphine maintenance treatment (MT), 288 entering detoxification (DTX), 180 entering drug-free residential rehabilitation (RR) and 80 not in treatment (NT). Treatment entrants were generally long-term heroin users with previous treatment experience. The majority of the sample (55%) were criminally active in the month preceding interview. Injection-related health problems (74%) and a history of heroin overdose (58%) were commonly reported. There were high degrees of psychiatric co-morbidity, with 49% reporting severe psychological distress, 28% having current major depression, 37% having attempted suicide and 42% having a lifetime history of post-traumatic stress disorder. Personality disorders were also prevalent, with 72% meeting criteria for antisocial personality disorder and 47% screening positive for borderline personality disorder. Striking similarities were noted between the non-treatment and treatment groups in length of heroin use career, drug use and treatment histories. [Ross J, Teesson M, Darke S, Lynskey M, Ali R, Ritter A, Cooke R. The characteristics of heroin users entering treatment: findings from the Australian Treatment Outcome Study (ATOS). Drug Alcohol Rev 2005;24:411-418]     

The association between cocaine use and short-term outcomes for the treatment of heroin dependence: findings from the Australian Treatment Outcome Study (ATOS)

The aim of this study was to determine the prevalence of cocaine use among individuals presenting for treatment for heroin dependence, describe the clinical profile of heroin users who also use cocaine and to establish the effects of cocaine use on short term outcomes for the treatment for heroin dependence. A longitudinal follow-up of 549 heroin users recruited in Sydney for the Australian Treatment Outcome Study was conducted at 3-month post-baseline interview. At baseline, current cocaine use was common (39%) and was associated with increased drug use, needle risk taking and criminality. The 3-month prevalence of cocaine use declined significantly to 19%. Thirty-five per cent of those who had used cocaine at baseline continued to use at 3 months, while 9% of the sample had commenced cocaine use. Those who entered residential rehabilitation at baseline were less likely than other treatment entrants and the non-treatment group to have used cocaine at follow-up. Treatment retention was not affected by baseline cocaine use status; however, baseline cocaine users (CU) displayed higher levels of heroin use, polydrug use and drug-related problems. A poorer outcome was associated with the commencement or continuation of cocaine use, while cessation of cocaine use resulted in significant improvements on these measures. Cocaine use was common among individuals seeking treatment for heroin dependence and was an important moderator of treatment outcome. It appears that cocaine use has a strong negative effect on treatment outcome over and above that caused by polydrug use generally. [Williamson A, Darke S, Ross J, Teesson M. The association between cocaine use and short-term outcomes for the treatment of heroin dependence: findings from the Australian Treatment Outcome Study (ATOS). Drug Alcohol Rev 2006;25:141 - 148]     

Outcomes after detoxification for heroin dependence: findings from the Australian Treatment Outcome Study (ATOS)

As part of the Australian Treatment Outcome Study (ATOS), 177 (88%) heroin users entering detoxification (DTX) and 66 (83%) heroin users not in treatment (NT) were interviewed at baseline and 3 months to examine drug use, risk-taking, overdose, crime and psychopathology outcomes. The majority (76%) of the DTX group had entered additional treatment at 3 months, mainly further detoxification, and 54% were currently in treatment, mainly maintenance and residential rehabilitation. There were reductions in heroin use and other drug use in those entering detoxification. Forty-two per cent were abstinent at 3 months compared to 20% in the NT group. There were also reductions in crime among those entering DTX, and less marked reductions in the NT group. Psychopathology showed less change. Detoxification may, in some part, function as a gateway to further treatment and those entering DTX showed modest but significant improvements across drug use and crime at 3 months. [Teesson M, Havard A, Ross J, Darke S. Outcomes after detoxification for heroin dependence: findings from the Australian Treatment Outcome Study (ATOS). Drug Alcohol Rev 2006;25:241 - 247]     

Young people with heroin dependence: findings from the Australian Treatment Outcome Study (ATOS)

This paper examines the patterns and correlates of heroin use in a cohort of 210 young Australians aged between 18 and 24, who were participants in the Australian Treatment Outcome Study, a longitudinal study of treatment outcomes for heroin dependence. Of major importance were the high rates of psychiatric comorbidity found among this group (37% lifetime Post Traumatic Stress Disorder, 23% current Major Depression, 75% Anti-Social Personality Disorder, and 51% Borderline Personality Disorder). Seventeen percent had attempted suicide in the preceding year. Although both the young (aged 18-24 years) heroin users and their older counterparts (aged 25-56 years) initiated drug use at the same age, young heroin users progressed to heroin use, regular heroin use, and treatment for heroin use, twice as quickly as older heroin users. These findings suggest that there is a limited window of opportunity in which early interventions may be applied before young heroin users progress to problematic use.     

Post-traumatic stress disorder among people with heroin dependence in the Australian treatment outcome study (ATOS): prevalence and correlates

This study documents the prevalence and correlates of post-traumatic stress disorder (PTSD) among Australian individuals with heroin dependence. Data was obtained from a cohort of 615 people dependent on heroin, 535 entering treatment for their heroin dependence and 80 individuals not in treatment. Trauma exposure (92%) and lifetime PTSD (41%) were highly prevalent. PTSD was prevalent across all treatment modalities, most commonly residential rehabilitation (52%) followed by maintenance therapies (42%), and detoxification (37%). The lowest prevalence was reported among those not in treatment (30%). Although men and women were equally likely to have experienced trauma (93% vs. 89%), women were more likely to develop lifetime PTSD (61% vs. 37%). For the large majority of those with PTSD, the condition was chronic (84%), with symptoms continuing for an average of 9.5 years. Those with PTSD had more extensive polydrug use histories, poorer general physical and mental health, and more extensive health service utilisation. It is concluded that PTSD is highly prevalent among individuals with heroin dependence, presenting a significant challenge to treatment providers.     

One year outcomes for heroin dependence: findings from the Australian Treatment Outcome Study (ATOS)

AIM: To determine 1 year outcomes for drug use, criminality, psychopathology and injection-related health problems in those entering treatment for heroin dependence in Australia. DESIGN: Longitudinal prospective cohort study. PARTICIPANTS: Seven hundred and forty five individuals entering treatment (methadone/buprenorphine maintenance therapy; detoxification; residential rehabilitation) and 80 heroin users not seeking treatment. SETTING: Sydney, Melbourne and Adelaide, Australia. FINDINGS: A total of 657 individuals were re-interviewed at 1 year, 80% of the original sample. There were substantial reductions in heroin and other drug use across all three treatment modalities. The majority of those who had entered treatment were heroin abstinent at 1 year (maintenance therapy 65%, detoxification 52%, residential rehabilitation 63%) compared to 25% of the non-treatment sample. The reduction in heroin use among the treatment samples was paralleled by reductions in poly drug use. There were also substantial reductions in risk-taking, crime and injection-related health problems across all treatment groups, and less marked reductions among the non-treatment group. Psychopathology was dramatically reduced among the treatment modalities, while remaining stable among the non-treatment group. Positive outcomes at 1 year were associated with a greater number of cumulative treatment days experienced over the 1 year follow-up period ('treatment dose') and fewer treatment episodes undertaken in that time ('treatment stability'). CONCLUSIONS: At 1 year, there were impressive reductions in drug use, criminality, psychopathology and injection-related health problems following treatment exposure. The positive findings were associated with a greater "dose" of treatment, and with more treatment stability over the follow-up period.     

Patterns of sustained heroin abstinence amongst long-term, dependent heroin users: 36 months findings from the Australian Treatment Outcome Study (ATOS)

AIMS: To determine patterns of past month, 12 month and sustained 36 month heroin abstinence. METHODS: As part of a longitudinal cohort study, 429 heroin users re-interviewed at 36 month follow-up for the Australian Treatment Outcome Study (ATOS). RESULTS: The proportion who had sustained heroin abstinence since baseline declined from 14% at 12 months to 8% at 36 months. The proportion who reported abstinence over the preceding 12 months, however, increased significantly from 14% at 12 months to 40% at 36 months. There were no significant gender differences in the proportions reporting sustained 36 month abstinence. Females, however, were significantly more likely to have maintained abstinence over the 12 months preceding 36 month follow-up. Independent predictors of sustained abstinence over 36 months were fewer treatment episodes since baseline, not committing crime at baseline and higher levels of global psychological distress. CONCLUSIONS: Despite a decline in the proportion who had maintained complete heroin abstinence over 36 months, there were substantial increases in 12 month abstinence patterns. The results illustrate the importance of stable treatment retention.     

Factors associated with 12 months continuous heroin abstinence: findings from the Australian Treatment Outcome Study (ATOS)

AIMS: To determine the role of treatment and client characteristics associated with the achievement of continuous heroin abstinence. DESIGN: Longitudinal cohort study. SETTING: Sydney and Adelaide, Australia. PARTICIPANTS: 570 heroin users re-interviewed at 12 month follow-up for the Australian Treatment Outcome Study (ATOS). FINDINGS: Continuous heroin abstinence was reported by 14% of participants. Continuous abstinence was associated with no previous treatment history, having entered treatment at baseline, and cumulative treatment exposure over the follow-up period. Longer retention times in index maintenance and residential rehabilitation treatments, but not detoxifications, were most associated with abstinence. At baseline, abstinent participants were more likely to have been classified as treatment ready, or to have used heroin less frequently; and less likely to have been daily injectors, using cocaine or criminally involved. CONCLUSIONS: Approximately 14% of ATOS participants achieved continuous heroin abstinence over 12 months. Such an achievement was strongly associated with a longer "dose" of treatment, and with more treatment stability over the follow-up period.     

Borderline personality disorder, antisocial personality disorder and risk-taking among heroin users: findings from the Australian Treatment Outcome Study (ATOS)

AIM: To determine the relationship between borderline personality disorder (BPD), antisocial personality disorder (ASPD) and harm among current heroin users. DESIGN: Cross-sectional survey. SETTING: Sydney, Australia. PARTICIPANTS: 615 current heroin users. FINDINGS: Forty-six percent met criteria for BPD, 71% for ASPD, and 38% met criteria for both diagnoses. ASPD was related to attempted suicide, lifetime overdose, polydrug use, depression and overall psychological distress. BPD was also related to each of these risk domains, and to needle risk and recent suicide as well. When analysed separately, both BPD and ASPD thus appeared to predict harm. For the purposes of further analysis, the relationships between BPD, ASPD and harm, the sample was divided into four independent diagnostic groups: no diagnosis (ND, 21%), ASPD only (ASPD, 33%), BPD only (BPD, 7%), ASPD plus BPD (DUAL, 38%). The division of the sample into four distinct diagnostic groups produced substantially different results. There were strong relationships between BPD and attempted suicide, needle sharing and psychopathology. In none of these domains did the ASPD group significantly differ from the ND group. Also, the levels of harm among the DUAL group were identical to BPD, suggesting no additive risk from ASPD. Thus, while initial analyses suggested an increased risk for ASPD patients for suicide and psychopathology, these relationships disappeared after BPD was taken into account. The only domain in which there appeared to be an additive risk for ASPD and BPD was heroin overdose. CONCLUSIONS: The extensive comorbidity between BPD and ASPD means that, unless BPD is controlled for, artefactual relationships may emerge between ASPD and harm.     

Depression among heroin users: 12-Month outcomes from the Australian Treatment Outcome Study (ATOS)

A cohort comprising 495 heroin users were interviewed for the Australian Treatment Outcome Study and were reinterviewed at 12-month follow-up. The rate of current major depression declined significantly from 26% to 11% for the follow-up period. Those with current major depression on follow-up experienced fewer total days in treatment, but engaged in more treatment episodes. In comparison to those without depression, depressed individuals had less exposure to methadone/buprenorphine maintenance and residential rehabilitation for the follow-up period, but spent more time in detoxification. Those with current major depression on follow-up also reported heavier heroin and other drug use, more risk-taking behaviors, poorer physical health, and greater psychopathology than those without a diagnosis of current major depression. Although caution in interpreting these relationships is advised given the potential for confounding by client characteristics, the findings of this study illustrate the need to consider depression in the treatment of heroin dependence.     

Attempted suicide among heroin users: 12-month outcomes from the Australian Treatment Outcome Study (ATOS)

A cohort of 495 heroin users, recruited for the Australian Treatment Outcome Study (ATOS), were re-interviewed at 12 months regarding suicide attempts over the follow-up period. The proportion who had attempted suicide in the 12 months since baseline was not significantly different from that reported in the 12 months preceding ATOS enrolment (12.2% versus 9.1%), and attempted suicide did not decline significantly in any of the index treatment groups. Among males, there was no significant reduction in attempted suicide (8.7% versus 8.1%). Among females, however, the proportion reporting an attempt declined significantly from 19.7 to 9.8%. Of those who reported suicidal ideation at baseline, 22.8% made an attempt over the follow-up period, as did 19.0% of those who had major depression. Large, and significant, declines in suicidal ideation (23.1% versus 6.9%) and major depression (25.5% versus 10.9%) occurred over the study period. Independent predictors of a suicide attempt over the follow-up period were: social isolation, having made an attempt in the preceding 12 months, suicidal ideation at baseline, a greater number of treatment episodes and higher levels of baseline polydrug use.     

Rates and correlates of mortality amongst heroin users: findings from the Australian Treatment Outcome Study (ATOS), 2001-2009

The study aimed to determine mortality rates, standardised mortality ratios (SMRs), and correlates of mortality amongst the Australian Treatment Outcome Study (ATOS) cohort of 615 heroin users over the period 2001-2009. The cohort was followed for a total of 4820.1 person years. A total of 31 deaths (5% of the cohort) occurred across follow-up. The mean age at death was 34.5 years, and 58% were male. The most common cause of death was overdose (68%). The crude mortality rate was 6.43 per 1000 person years, with no gender difference, and the SMR was 4.56 (males = 2.95, females = 18.57). The only significant bivariate (hazard ratio = 3.69) and multivariate (adjusted hazard ratio = 3.03) correlate of mortality was a history of opioid overdose prior to baseline. Mortality rates were lower than those seen outside Australasia. Screening for overdose by those treating heroin users would be appropriate, and may contribute to reductions in overall mortality.     

Overdose deaths following previous non‐fatal heroin overdose: Record linkage of ambulance attendance and death registry data

Introduction and Aims. Experiencing previous non‐fatal overdoses have been identified as a predictor of subsequent non‐fatal overdoses; however, few studies have investigated the association between previous non‐fatal overdose experiences and overdose mortality. We examined overdose mortality among injecting drug users who had previously been attended by an ambulance for a non‐fatal heroin overdose. Design and Methods. Using a retrospective cohort design, we linked data on non‐fatal heroin overdose cases obtained from ambulance attendance records in Melbourne, Australia over a 5‐year period (2000–2005) with a national death register. Results. 4884 people who were attended by ambulance for a non‐fatal heroin overdose were identified. One hundred and sixty‐four overdose deaths occurred among this cohort, with an average overdose mortality rate of 1.20 per 100 person‐years (95% CI, 1.03–1.40). Mortality rate decreased 10‐fold after 2000 coinciding with widely reported declines in heroin availability. Being male, of older age (>35 years) and having been attended multiple times for previous non‐fatal overdoses were associated with increased mortality risk. Discussion and Conclusions. As the first to show a direct association between non‐fatal overdose and subsequent overdose mortality, this study has important implications for the prevention of overdose mortality. This study also shows the profound effect of macro‐level heroin market dynamics on overdose mortality.[Stoové MA, Dietze PM, Jolley D. Overdose deaths following previous non‐fatal heroin overdose: Record linkage of ambulance attendance and death registry data. Drug Alcohol Rev 2009;28:347–352]     

Depression among entrants to treatment for heroin dependence in the Australian Treatment Outcome Study (ATOS): prevalence, correlates and treatment seeking

AIM: To determine the rate of current major depressive disorder (MDD) among entrants to treatment for heroin dependence in three treatment modalities and a non-treatment comparison group; and to ascertain factors associated with depression. DESIGN: Cross sectional structured interview. SETTING: Sydney, Australia. Participants: 615 current heroin users: 201 entering methadone/buprenorphine maintenance (MT), 201 entering detoxification (DTX), 133 entering drug free residential rehabilitation (RR) and 80 not in treatment (NT). FINDINGS: Current major depressive episode was reported by 25%. The rates of major depressive disorder ranged from 26% in the treatment groups (23% MT, 25% DTX, 31% RR) to 16% of those not in treatment. Females were more likely to have current major depressive episode (31% versus 21% OR 1.70, 95% CI 1.16-2.48). Factors associated with depression in the treatment groups were post traumatic stress disorder (PTSD), attempted suicide in the last 12 months and severe physical disability. Among the non-treatment group those with depression were also more likely to have PTSD. Women entering treatment were three times more likely to meet criteria for current major depression than women not in treatment. Among men however, the rates were not significantly different. CONCLUSION: Depression is a significant concern among entrants to treatment for heroin dependence. An essential component of treatment should be a consideration of depression, with the provision of appropriate treatment were required.     

The ACT heroin trial: intellectual, practical and political challenges

An array of intellectual, practical and political challenges will be faced both if the Australian Capital Territory "heroin trial" does or does not eventuate. The intellectual challenges include the development of new methodologies and analytical tools for some of the outcome measures; the further development of a research process which involves all the relevant disciplines and interest groups; and capitalizing on an unprecedented opportunity to investigate the pharmacokinetics of heroin. The practicalities of setting up a trial also present a number of challenges, as does incorporating a health development approach. Political challenges include getting a sensible decision made about the trial, avoiding capture of the debate by supporters or opponents of drug law reform and avoiding unrealistic expectations. The major challenge if the trial does not go ahead is to implement other well-considered proposals which can be carefully evaluated.     

Patterns and correlates of attempted suicide by heroin users over a 3-year period: findings from the Australian treatment outcome study

In order to determine patterns and correlates of attempted suicide amongst heroin users across 3 years, a cohort of 387 heroin users (134 entering maintenance treatment, 134 entering detoxification, 81 entering residential rehabilitation and 38 not entering treatment) were interviewed about suicide attempts at baseline, 12, 24 and 36 months. Across the follow-up period, 11.6% attempted suicide. There were declines in the proportion who attempted suicide each year amongst both males and females and significant declines in Major Depression, suicidal ideation and current suicide plans. Despite this, levels of attempted suicide, suicidal ideation and Major Depression in the cohort remained higher than in the general population. Those who had made a previous suicide attempt were five times more likely to make an attempt across follow-up and there was a strong association between an attempt in any 1 year and increased probability of an attempt in the subsequent year. A quarter of those who reported suicidal ideation at baseline made an attempt across follow-up. At each interview point, current suicidal ideation was strongly associated with increased risk of a suicide attempt in the following year. Independent predictors of a suicide attempt across follow-up were a lifetime suicide history, baseline suicidal ideation, social isolation and the extent of baseline polydrug use. Given the strong predictive value of suicidal ideation and previous attempts, regular brief screening would appear warranted to identify those at greatest risk.     

Benzodiazepine use among heroin users: Baseline use,current use and clinical outcome

Introduction and Aims. Benzodiazepine use is associated with elevated levels of harm. The current study aimed to ascertain the long‐term nature of the relationship between benzodiazepine use and clinical profile among heroin users. Design and Methods. Longitudinal cohort, with follow‐up at 3, 12, 24 and 36 months. Participants were 615 heroin users recruited for the Australian Treatment Outcome Study. Results. At baseline, current benzodiazepine users were more likely to be committing crime, had poorer psychological health and poorer physical health. Baseline benzodiazepine use was not associated with the likelihood across follow‐up of heroin use (P = 0.44), committing crime (P = 0.17), poorer psychological health (P = 0.31) or poorer physical health (P = 0.48). Current benzodiazepine use was, however, associated with a greater likelihood of concurrent heroin use (OR 2.77), crime (OR 2.04), poorer psychological health (β = −4.47) and poorer physical health (β = −2.33). Discussion and Conclusions. Clinicians should be aware that reductions in benzodiazepine use are associated with reductions in harm, and that baseline benzodiazepine status does not equate to poor long‐term outcome. [Darke S, Ross J, Mills K, Teesson M, Williamson A, Havard A. Benzodiazepine use among heroin users: Baseline use, current use and clinical outcome. Drug Alcohol Rev 2009]     

Attempted suicide among entrants to three treatment modalities for heroin dependence in the Australian Treatment Outcome Study (ATOS): prevalence and risk factors

AIMS: To determine the lifetime and recent histories of attempted suicide among entrants to treatment for heroin dependence in three treatment modalities and a non-treatment comparison group; and to ascertain factors associated with a recent history of attempted suicide. DESIGN: Cross-sectional structured interview. SETTING: Sydney, Australia. PARTICIPANTS: Six hundred and fifteen current heroin users: 201 entering methadone/buprenorphine maintenance (MT), 201 entering detoxification (DTX), 133 entering drug free residential rehabilitation (RR) and 80 not in treatment (NT). FINDINGS: A lifetime history of attempted suicide was reported by 34% of subjects, 13% had attempted suicide in the preceding year and 5% had done so in the preceding month. Females were more likely to have lifetime (44% versus 28%) and 12 month (21% versus 9%) suicide attempt histories. The 12 month prevalence of attempted suicide among treatment groups ranged between 11% (MT, NT) and 17% (RR). Factors associated with recent suicide attempts were: being an RR entrant, female gender, younger age, less education, more extensive polydrug use, benzodiazepine use, recent heroin overdose, Major Depression, current suicidal ideation, Borderline Personality Disorder (BPD)and Post-Traumatic Stress Disorder. CONCLUSIONS: Recent suicidal behaviour is a major clinical problem for heroin users, and for females and RR entrants in particular. An essential adjunct to treatment for heroin dependence is routine screening for depression and suicidal ideation, with the provision of appropriate treatment where needed.     

Estimating the client costs of addiction treatment: first findings from the client drug abuse treatment cost analysis program (Client DATCAP)

The costs of addiction treatment services are an important determinant of the cost-effectiveness of a program, and therefore, of relevance to addiction treatment providers, insurance companies and, patients. Several methods have been developed to estimate the costs of substance abuse treatment services. One such method is the drug abuse treatment cost analysis program (DATCAP), which collects resource use and cost data from the treatment program perspective and has been used in numerous published economic evaluation studies. However, no single widely-used, standardized instrument is currently available to estimate costs specifically incurred by clients in treatment. In response to that need, this article introduces the Client DATCAP and presents process, survey-specific, and quantitative findings from a Pilot Study to estimate the client costs of attending outpatient and inpatient treatment. The preliminary findings suggest that the self-administered Client DATCAP is a feasible and practical instrument for estimating costs incurred by clients in treatment, with completion time amounting to less than 10 min. Furthermore, client costs had a considerable range across respondents, with time costs consistently accounting for the largest cost component. Findings from the Pilot Study led to the development and release of edition 2 of the outpatient and inpatient modules of the Client DATCAP.